Date: 8 June 2013
Our ref: TD/001130560/10
Reference: 210965776919/055 /E5142
Member Number: 001130560
Dependant: 00
Option: EMERALD

MS NZ MBOTHO
PRIVATE BAG X508
KOKSTAD
4700

Dear Ms Mbotho
Summary Information of Healthcare Expenditure as at 28/02/2013
This letter provides you with a summary of information regarding your healthcare expenditure for submission to
the South African Revenue Service (SARS). The benefit and contribution amounts shown below are for claims
paid and contributions the Scheme received during the period 01/03/2012 to 28/02/2013.
Your portion paid on contributions: R0.00
Total number of beneficiaries (including principal member) per month:
March

April

May

June

July

Aug

Sep

Oct

Nov

Dec

Jan

Feb

0

0

0

0

0

0

0

0

0

0

0

3

The above contribution amount is calculated for members who pay their contributions to the medical scheme
via cash or debit order. If R0.00 is reflected, your full contribution is received via your employer. Please refer to
your IRP5 form to calculate your portion paid.
Your portion paid on claims: R0.00
The amount reflected above is the difference between the amount charged by the service provider and the
benefit amount/limit covered by the medical scheme. It is your responsibility as the principal member to provide
proof that this amount was paid to the service provider.
Please note that this amount shows only those claims that were processed up until 28/02/2013. Any claims with
treatment dates that fall in this period, but that were not processed by this date, will be included in your
Summary of Healthcare Expenditure for 2014.
Yours sincerely
Customer Services Department
Disclaimer:
Every effort has been made to ensure that all information provided to you is factual and accurate. However, in
the event of a dispute, the Scheme Rules shall apply. You can view the Scheme Rules on our website at
www.gems.gov.za under the ´About Us´ section on the Menu. Please note that GEMS is not a financial service
provider and is prohibited by law from giving any financial advice.

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