Terms of Service

ClaimIQ is a medical aid claim review and dispute service. We help South African members overturn rejected or underpaid claims and dispute hospital debt. Our core service lines are:

• Rejection Reversal
• PMB (Prescribed Minimum Benefit) Enforcement
• Hospital Debt Erasure
• CMS Escalation

ClaimIQ is not:

• a medical scheme, medical scheme administrator or broker;
• a Financial Services Provider under the Financial Advisory and Intermediary Services Act 37 of 2002 (“FAIS”) — we do not sell financial or insurance products and do not provide financial or investment advice;
• a firm of attorneys — this is an administrative, clinical and dispute-resolution service, not legal representation, unless a qualifying attorney is separately engaged.

You may use our service if you are 18 years or older and a member (or authorised representative of a member) of a South African registered medical scheme, with a claim you believe was wrongly rejected or underpaid, or hospital debt you believe should have been covered.

You warrant that:

• the information you provide (identity, contact, scheme, plan, event description, claim amount) is accurate and complete;
• the documents you upload (rejection letters, hospital bills, discharge summaries, clinical notes) are genuine and lawfully in your possession;
• you have the right to instruct us on the claim, and if you are acting on behalf of another member, that you are authorised to do so;
• you will respond within a reasonable time to requests for further information.

If information is materially inaccurate or documents are withheld, we may pause or terminate the mandate without refund of the Case Review fee.

Our fees are set out in full in theRefund Policyand are summarised below:

• Tiered flat Case Review fee — one once-off flat fee per claim, set by the disputed claim amount you enter at intake:
  • Tier 1 — Standard (up to R10,000): R500
  • Tier 2 — Elevated (R10,001 – R50,000): R1,500
  • Tier 3 — Complex (over R50,000): R3,000
  The applicable tier fee is charged before we begin the review and is non-refundable once work starts.
• No success fee, no commission, no percentage — the applicable tier fee is the only fee we charge per claim reviewed. We take no cut of any amount recovered from the medical aid or written off by the hospital / provider.

You acknowledge that part of the review is performed by an automated AI clinical audit pipeline, with human clinical / dispute review before submission to the scheme. Full disclosure is provided in thePOPIA Notice.

We apply reasonable skill and care to every matter, but we cannot and do not guarantee that a rejected claim will be overturned, that PMBs will be paid in full, or that hospital debt will be written off. Outcomes depend on the scheme rules, the clinical facts, the strength of the underlying documentation and the discretion of the scheme, CMS or hospital.

All content on the ClaimIQ platform — including the dispute engine, audit outputs, letter templates, PMB motivation frameworks, checklists and branding — is owned byClaimIQ or licensed to us. You are granted a limited, personal, non-transferable licence to use the audit outputs, corrected claim summaries and resubmission letters we generate for your own claim. You may not resell or redistribute them.

To the maximum extent permitted by South African law, ClaimIQ’s total aggregate liability to you arising from or in connection with our service is limited to the total fees actually paid by you to us in respect of the matter giving rise to the claim. We are not liable for indirect, consequential, special or punitive damages, or for loss of profit, goodwill, savings or expected recoveries.

Nothing in this section limits any right you have under the Consumer Protection Act 68 of 2008 or any other liability that cannot lawfully be excluded.

You may terminate the mandate in writing at any time by emailingsupport@claimiq.co.za. Termination does not affect the tier Case Review fee already paid (which is non-refundable once work has commenced). We may terminate the mandate if you fail to co-operate, provide inaccurate information, or act unlawfully in relation to the claim.

These Terms are governed by the laws of the Republic of South Africa. You consent to the non-exclusive jurisdiction of the Magistrate’s Court or the High Court of South Africa (as applicable), notwithstanding that the amount in dispute may exceed the Magistrate’s Court’s jurisdiction.

We may update these Terms from time to time. The latest version will always be available on this page with an updated effective date. Material changes will be communicated to active clients by email.

ClaimIQ SA (Pty) Ltd
Registration No.: [Pending CIPC Registration]
Email: support@claimiq.co.za