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Our ref: E5142 /l'D/2309829062131 Date: 10 May 2020

Reference: 2309829062'1 3/055 lE51 42

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Member Nr:mber: 00067 4544
MRS DN MATJIU
Dependant 00
43 STANLEY ROAD
Option: EMERALD
DUNNOTTAR
1496

Dear Mrs Matjiu

Sttmnrary lnformation of Healthcare Expenditure as at 2910?"120?.0

This letter provides you with a summary of lnfonnation regarding your healtlrcare expenditure for subntission to the South
African Revenue Setvice (SARS), Tho benofit and contiibr"rtiorr anroun{s shown below are for clainrs paid and
contlibutions the Schenre receivecl during the period 01/03/20'19 lo ?-Q102120?-0.

Total contributions paid: R20559.00

Total number of boneficiarios (including principal nrenrber) per month;

Mar Apr May Jun Jul Aug sep Oct Nov Dec Jan Feb
1 1 1 1 1 1 1 (.) 0 0 0 0

The above contribLttion arnounl is caloulated using the full contribution received fiom youl enrployer', and the contribution
component paid by members to the nredical sclrerrre through cash or debit order, Please refer to your lRPS fonn to
calculate your potlion paid.

Your portion paid on claims: R57757.02

'Ihe amount reflected

ahove is the diffelence between the anrount chargecl by the service provider ancJ the Llenelit
anlountllimit covered by the medical sclreme. lt is your responsibility trs the principal mentber to provide proof that this
anrount was paid to the service provider'.

Please note that this antount shows only those claints that were prr.rcesserJ Ltlt rrtil ?..9t021?-020. Any claims with
treatment dates that fall in this period, but that were not processed by this clate, will be inclucied in your Sumnrary of
Healthcare Expenditure for 2021.

Yours sincerely

Cu$tonrer Selvices Departntent

Disclaimer:
Every effort has been tnade to ensure that all information proviclecj to you is factual ancl accurate, However, in
the event of a dispLrte, the Scherne Rules shall apply. YoLr can view the Scheme Rules on our website at
www,gen'ls,gov,za. The infotmation provicled r:n this correspondence is foiinformation purposes only and
cannot replace meclical advice frorn your professional healthcare provicler, Plsase note that GEMS is not a
financial selvice provider ancl is prohibited by law fronr givirrg any financial advice.

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