How to Claim

In the event that a member pays 100% for medical services, PULA will reimburse them according to the Fund rules and agreed tariffs. Claims should be submitted for payment within a period of three (3) months from the date of service.

For all claims submitted, please ensure the following details are correct:

  • Member’s first name and surname as written on the membership card.
  • Name of the benefit option.
  • Membership number
  • Name and signature of healthcare professional providing the service
  • The date on which service was provided
  • Itemised list of all services and their respective individual charges. In the case of a medical practitioner or dentist, a diagnosis of the complaint for which the service was provided, as well as tariff codes for the respective services where applicable.
  • All invoices for pathology/laboratory services, speech therapy, physiotherapy, dietetics, occupational therapy, psychology, or any other paramedic/allied/associated health services should be accompanied by a copy of the letter of referral from a medical practitioner or dentist.
  • Invoices for medication dispensed by a pharmacy should be accompanied by a copy of the prescription certified by the pharmacist, as a true and exact photocopy of such prescription
  • When submitting claims for payment, always attach receipt of payment.  We do not accept receipts alone for claims without proof of payment.
  • All invoices should be signed by the member or dependent to acknowledge receipt of services being claimed for.

Refunds to members are normally done electronically; therefore we require the following information:

  • Account name
  • Account number
  • Bank name
  • Branch number
  • Branch code
  • Account type (savings, current or cheque)

How long does it take to pay claims?

  • Claims are paid once every week, ensuring that your submitted claims are captured, processed and paid into your account within reasonable time.

What is the criterion for assessment of claims?

  • The fund pays 90% of the invoiced amount from the healthcare service provider provided it does not exceed the agreed tariff.
  • Claims are paid in accordance with the Fund Rules and subject to availability of benefits.

How do I send claims from outside Botswana?

  • Ensure the details are correct and itemised accordingly.
  • We accept both hand delivered, scanned and emailed and posted original invoices.
  • As a precaution members are encouraged to make copies of all their submissions.

Who can submit claims?

  • Members, dependants but refunds are paid to the Principal member’s bank account.

When do I get my statements?

  • Statements are sent to members every time a claim is paid, whether submitted by a healthcare provider or member or dependent.

What does ‘due by you’ mean?

  • “Due by you” refers to the co-payment that the member has to pay for the services that have been invoiced by a healthcare service provider. It is the 10% that the member would have paid at the doctor’s office or at the pharmacy when medication was dispensed.