Member Application Form

TopMed Medical Scheme
P.O. Box 2338
Durban
4000
Client Services: 086 000 2158
Website: www.topmed.co.za
 
A. Employment Details (including self-employed)
Name
Existing Group Number
Postal Address
 
 
 
Postal code
         

B. Personal Details
Surname Title    
Full Name(s) Initials    
Principal Member
Gender
Male Female
 
Language Preference
English Afrikaans
   
Identity / Passport Number
  Race    
Country of Origin
Employee Number
Date of Employment
Cellular Phone No.
Telephone No. (h)
Telephone No. (w)
Physical address
 
     
 
Postal code
        
   
Postal Address
 
 
 
Postal code
        
   
E-mail address
Would you like your statements e-mailed to you?
Marital status


   
   
   
   

C. Dependants (to be registered) If this space is insufficient, please attach another page with information regarding additional dependants.

Full name(s)
Surname
Gender
M / F
ID number
Relationship
(spouse, son, partner, etc)

 

Please note that section 5 must be completed when new dependants are added.
* Partner – a person with whom the Member has a committed and serious relationship similar to that of a marriage in which
there is mutual financial and emotional support and a shared household, irrespective of the gender of either party.
   
D. Details of previous medical scheme membership required if applicant and/or dependants (older than 21) of the applicant
belonged to another medical scheme
   
A membership certificate from your or your dependants' present/previous medical scheme(s) is required. If a membership certificate
cannot be supplied, please provide an affidavit with all the information regarding your and your dependants' (older than 21 years) present/previous medical scheme(s) cover.
 
Have you ever been a member of another medical scheme?
If Yes, please supply details of scheme(s)
     
   
Name of Scheme
Membership No.
Date of Joining
Resignation Date
   
Name of Scheme
Membership No.
Date of Joining
Resignation Date
   
Name of Scheme
Membership No.
Date of Joining
Resignation Date
   
E. Underwriting Questions  
PLEASE ANSWER "YES" OR "NO" FOR EVERY QUESTION ("Y" or N")
1 High blood pressure, high cholestrol or lipids, Ischaemic heart disease, Heart failure, Angina, Stroke (CVA) or Peripheral vascular disease.
2 Obstructive lung disease (asthma, emphysema or COAD)
3 Diabetes (insulin or non-insulin dependant diabetes mellitus)
4 Hypo or hyperthyroidism
5 Arthritis, i.e. osteo and rheumatoid arthritis or gout and all related musculoskeletal conditions
6 Osteoporosis
7 Gastro-Oesophageal reflux disease (gord/heartburn) or stomach and duodenal ulcers (please circle)
8 Immune deficiency states i.e. HIV/AIDS*, immunoglobulin deficiencies
9 Anaemia or abnormalities of clotting mechanism
10 Hormone replacement therapy, endometriosis or ovarian cysts
11 Depression and/or anxiety disorders
12 Any nervous or mental complaint e.g epilepsy, blackouts, paralysis or headaches
13 Glaucoma, cataracts or any other disorders of the eye
14 Parkinson's disease or Multiple Sclerosis (please circle where applicable)
15 Hyperplasia of prostate (BPH) or prostatitis
16 Inflammatory Bowel Disease (Crohn's Disease or Ulcerative Colitis)
17 Urinary tract infection or calculi (kidney) stones
18 Back or neck related conditions (lumbago, sciatica, injury, spasm etc)
19 Are you pregnant, if so how many weeks?
20 Have you had any surgical procedure during the past 12 months or planning a surgical procedure for the following 12 months
21 Are you on any medication at present?
22 Is there any other condition or symptom, which is not detailed above, for which
medical advice, diagnosis, care or treatment has already been recommended or received, or could potentially result in a medical aid claim within the next 12 months.
23 Skin conditions/disorders e.g Acne, Eczema, Psoriasis etc
24 Ear, nose or throat disorders, e.g. ear discharge, recurrent tonsillitis
25 Infectious diseases e.g Tuberculosis. Shingles, measles etc
26 Malignant neoplasms (Cancer, growths or malignant tumours)
27 Benign Neoplasms (non malignant tumours/growths)
28 Specialised dentistry /maxillo facial treatment
29 Have you had or are you expecting to have Plastic or reconstructive surgery?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  * Should you be HIV-positive and not wish to disclose this on your application form, please note that once you have received your
membership (contract) number we require you to please fax confirmation of your HIV/Aids status to our HIV/Aids Department on 086 609 3792 or (012) 675 3848. Please note that this may result in you receiving a second card from the Scheme depending on whether your application will require underwriting as per current legislation.
 
No.
 Nature and duration of complaint and full details
of treatment being received or expected to be received		 Name and telephone number
of attending doctor or hospital		 When did you last have symptoms or last receive treatment ?
 
NB: Failure to disclose any pre-existing conditions could result in benefits being limited, excluded and /or membership terminated.
     
  F. Option Selection  
  Please confirm your selection - tick the relevant box:
NB: The correct choice of option is important, as changes may only be made annually for 1 January each year.




Topmed Traditional

Topmed Incentive Savings
Topmed Incentive Comprehensive
Topmed Hospital Plan
Topmed Network (please tick your salary band below)
Salary Band <R 3500
R3 501 - R7 500
R7 501 - R13 000
> R 13 000
     
 
Banking Details of Applicant
(For direct payment of monies DUE to members)		 Banking Details of Applicant
(For direct payment of monies DUE to members)
Name of Account Holder Name of Account Holder
Bank Name Bank Name
Branch No. Branch No.
Account No. Account No.
Account Type
Account Type
(C=Current, T=Transmission, S=Savings) (C=Current, T=Transmission, S=Savings)
     
  G. Application checklist
     
  Please enclose the relevant documentation with this form.
Important: Registration will be delayed should this application be incomplete or the required documents not attached, as it will be returned to you.
  Copy of recent salary statement and/or latest SARS return (For PERSAL and/or Network members)
Original cancellation letter to previous medical scheme (for PERSAL members)
Membership certificate(s) or affidavit of previous medical scheme(s)

       
     
  H. Declaration by applicant  
     
  I, the undersigned, apply for the membership as set out in this application for myself (and the registration of my dependants).
I acknowledge that I (and my dependants) will not be considered as members of Topmed until I receive written confirmation of membership.
The scheme, or its agents may from time to time do the following in respect of me (and any of my dependants):
• Request and receive any medical and medically related information that is relevant to consider this application and any
claim-related benefits for me (and any of my dependants for whom this application is accepted). Such information may be obtained from any healthcare provider or healthcare facility.
• Communicate any medical and medically related information from any healthcare provider or healthcare facility to the scheme's contracted healthcare management company. The purpose of this exchange is to ensure that the most cost-effective and high quality medical care benefits are obtained for all members of the scheme.
I further give my permission for:
• The required information to be requested, communicated and received at any time. This may even be after my death (or that of any of my dependants).
• Any failure to comply with a financial duty towards the scheme to be registered with a credit bureau.
I warrant that the information in this application, whether it is in my own handwriting or not, is complete and correct. This also
applies to information in other documents provided by me, any of my dependants, or healthcare provider or healthcare facility. If any information is not complete or correct the Scheme may cancel my membership in full. The scheme may also cancel my membership in full if the incomplete or incorrect information pertains to any of the dependants. Otherwise the Scheme may cancel the registration
of the dependant regarding whom the information was incomplete or incorrect. In either case, I shall forfeit the full contributions already paid to the Scheme, or the contributions for the dependant who has been removed from my membership. If my membership
is cancelled in full, I shall also pay back to the Scheme all benefits paid out to me and any of my dependants. If a dependant
is removed from my membership, I shall pay back all benefits paid for such a dependant.
I undertake to advise Topmed of any change in my state of health (or that of any of my dependants) which occurs prior to my receiving written acceptance of this application.
If any of the medical details that I have supplied in this application change before my membership starts, the Scheme may reconsider my application.
The Scheme, at its own discretion and even after my membership has started, may reconsider the full application, or only that of a certain dependant. If this is the case, the terms as explained in this declaration will apply.
I understand that the relationship between me (and any of my dependants) and the Scheme is controlled by the rules of the Scheme. I undertake to familiarise myself (and any of my dependants) with the rules of the Scheme, as well as the changes that are made to the rules from time to time.
  Signature of applicant: _________________ Date signed          
  Signature of employer: _________________ Date signed          
  Company Stamp Date signed          
     
  I. Details of the intermediary  
  Brokerage name
  Brokerage code
  Broker name
  Tel. No.
  Signature _______________   Date signed          
     
  J. The Rules  
  1. The Rules of Topmed, as amended from time to time, is binding on the Topmed Individual Member.
2. The person signing the contract on behalf of, or, as the Employer, acknowledges that he has received a set of Rules and that he has read them prior to signing this Contract.
3. Certain Rules are set out in summary hereunder so as to emphasise the Rules which Topmed considers to be particularly important. The failure to draw the Employer's attention to any Rule shall not in any way be regarded as excusing the Employer from the Employer's obligation to thoroughly acquaint himself with the Rules which have been delivered to the Employer. The summary is as follows:
     
  Rule Reference  
  1. The amounts set out in the Rules are payable by or in respect of Members and each of their Dependants. All such amounts are due monthly in advance, and payable by the fourth business day of every Month. The first such amount is payable from the first of the Month in which a Beneficiary's Inception Date falls, even if a waiting period applies to a Beneficiary.
2. When a Minor Dependant becomes an Adult Dependant the contribution applicable to an Adult Dependant is payable from the first day of the month following that in which the Minor Dependant becomes an Adult Dependant.
3. When Dependants are deregistered, decreased amounts are payable from the first of the Month after the Month during which the Dependants' deregistration took effect.
4. Beneficiaries who are Late Joiners are subject to the penalties set out in Annexure A of the Scheme rules. Those penalties also apply to Beneficiaries who were subject to similar penalties at previous medical schemes of which they had been members or dependants of members. However, any years of Creditable coverage which can be demonstrated by the Beneficiary is subtracted from that Beneficiary's current age in determining the applicable penalty.
5. Where Contributions or any other debt owing to the Scheme have not been paid within fourteen (14) days of the due date, the Scheme has the right to suspend payments of all Benefits which have accrued to such member irrespective of when the claim for such Benefit arose. The Scheme further has the right to give the Member notice that, if Contributions or such other debts are not paid within fourteen (14) days, membership may be cancelled without further notice.
6. If payments are brought up to date, Benefits must be reinstated without any break in continuity subject to the right of the Scheme to levy a reasonable fee to cover any expenses associated with the default and to recover interest at the prime overdraft rate of the Scheme's bankers. If such payments are not brought up to date, no Benefits will be due to the Member from the date of default and any such Benefit paid may be recovered by the Scheme.
7. The Scheme may withhold, suspend, or discontinue the provision of a Benefit, or of any right in respect of that Benefit, if the Member attempts to transfer, pledge, or hypothecate it.
8. Not withstanding anything to the contrary contained in the Rules, where the Employer/Individual gives late notification to Topmed of termination, the Employer/Individual shall be liable to pay Contributions payable up to the end of the month during which Topmed receives notification of termination.
     
  K. Additional Terms  
  1. Topmed is not obliged to pay any Benefits where the Member is in breach of any of the Member's obligations in terms of the Rules and in particular where any Contribution or part thereof is in arrear.
2. The Employer is the agent of the Member and not of Topmed in dealings between an Employee and Topmed.
3. The Employer/Member must notify Topmed within 30 days of any change of address and failure to notify will absolve Topmed from any liability should the Employer or Member's rights be prejudiced or forfeited
4. The Employer/Individual shall only be entitled to terminate the Group's Membership of Topmed consequent upon 3 calendar month's written notice of termination having been given to Topmed.
     
 
Topmed Medical Scheme reserves the right to list members who are found guilty of committing unethical behaviour , abuse, collusion, or fraud onto the Transunion ITC. This information maybe viewed by all of the medical schemes that have a contract with the Board of Healthcare Funders Forensic Management Unit.