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Sanlam Medical Gap Cover Insurance

What is Gap Cover

Gap Cover is a non-life insurance product that provides an extra layer of financial protection for those who already have medical aid. It helps to cover certain shortfalls between what your Medical Scheme will pay and the rates charged by in-hospital medical specialists.

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From R262 for individuals, and R459 for families, Sanlam Gap Cover Insurance provides for the difference between what your medical aid pays and the rates charged by medical specialists.

In certain cases the cost for in-hospital procedures or outpatient treatment may exceed the base medical aid rate by an additional six times. By taking out Sanlam Medical Gap Cover Insurance, you ensure that you and your family aren’t left with a large excess amount to settle.

How Medical Gap Cover Insurance works

Note: Graph values show actual payments made by medical aid schemes
and gap cover amounts paid out by Kaelo Risk (Pty) Ltd (FSP:36931),
the administrator for Sanlam Gap Cover.

2024 BENEFITS

Sanlam Comprehensive Gap Cover Plan

Individuals younger than 60 years
R262.00*
Families younger than 60 years
R459.00*
Individuals older than 60 years
R526.00*
Families older than 60 years
R916.00*

Benefits

Tariff shortfalls
The difference between the specialist’s fee and the medical scheme tariff.

Additional six-times medical aid tariff

Sub-limits
A sub-limit is a limit when a medical scheme imposes a rand limit, known as a sub-limit, on certain in-hospital medical procedures or prosthetic devices and a shortfall occurs.

R64,500 per event/condition

Co-payments
The excess payable upfront to the hospital before treatment or a procedure.

Subject to the Key Benefit Limit

Deductibles
A deductible is a co-payment payable by a member on admission to hospital.

Subject to the Key Benefit Limit

Penalty co-payment

A maximum of two such events are covered under this benefit per annum and up to a maximum amount of R18,550 per event, subject to the Key Benefit Limit.

For further benefits please download the Sanlam Gap Retail Brochure for 2024.

Benefits

Co-payments
The excess payable upfront to the hospital before treatment or a procedure.

  • MRI Scans: A CT scan is best suited for viewing bone injuries, diagnosing lung and chest problems, and detecting cancers. An MRI is suited for examining soft tissue in ligament and tendon injuries, spinal cord injuries, and tumours. CT scans are widely used in emergency rooms because the scan takes less than five minutes. An MRI, on the other hand, can take up to 30 minutes.
  • Oncology: Oncology is a branch of medicine that deals with cancers and tumours.

MRI/CT scans: Unlimited
Oncology sub-limits: Limited to statutory maximum of R198,660 per insured per annum

Accidental Casualty Benefit
The Casualty Benefit will pay for the facility fee and consultation associated with admissions into the emergency room or casualty ward of a private hospital.

Subject to a maximum of R18,450 per event

Child Casualty Benefit
Benefits relating to this clause will only be paid in respect of emergency out-patient services that are provided within a casualty ward of a hospital. The benefit is only payable in the event of after-hours treatment in an emergency situation. After-hours is Mondays to Fridays between 18:00 and 08:00 and all-day Saturdays, Sundays and South African public holidays. The benefit payable is equal to the total cost of treatment less the amount paid by your medical scheme from your hospital/risk benefit. If payment is made from your available medical savings account, or from your own pocket, we will reimburse that too.

Subject to a maximum of two such events per annum and a maximum of R2,860 per event. Limited to children under age 12

For further benefits please download the Sanlam Gap Retail Brochure for 2024.

Benefits

Hospital Cash Benefit
A cash payment you receive for every day you spend in hospital due to an accident or premature birth (more than 41 days before the originally expected natural birth date of 40 weeks).

If you’re a Sanlam Reality member, please refer to the Sanlam Reality section for more information on your Hospital Cash Benefit.

A maximum of two hospital episodes are covered under this benefit per annum, up to a maximum amount of R29,300 per annum. The benefit is payable from day one of the hospital episode: R480 per day from the 1st to the 13th day (inclusive). R860 per day from the 14th to the 20th day (inclusive). R1,700 per day from the 21st to the 30th day (inclusive). Max R29,300 per annum.

Family Booster
The natural or surgically assisted birth of one or more infants that occurs more than 41 days before the originally expected natural birth date of 40 weeks as verified by the clinical records of the mother's attending physician.

Lump sum Benefit is R15,900.

Family Protector
The lump sum benefit is payable upon the death or permanent disability of an insured party due to accidental harm.

Limited as follows:

Children below six years: R20,000

All other insured parties: R30,000

Medical scheme and the Sanlam Gap Policy contribution waiver
The benefit payable is equal to the monthly medical scheme and gap contribution applicable after the qualifying event, multiply by six and subject to an overall annual limit. This benefit is limited to one event over the policy lifetime.

The benefit payable is subject to an overall maximum limit of R35,500

Dental reconstruction
The lump sum benefit will only be paid in the event of dental reconstruction surgery being required as a direct result of accidental harm or from oncology Treatment that occurred after the inception of this policy.

A maximum of two such events are covered under this benefit per annum and up to a maximum amount of R49,900 per annum subject to the Key Benefit Limit

Road Accident Fund (RAF) claims

An end-to-end legal service is provided by the nominated service provider of Kaelo Risk to assist insured members with legitimate claims against the Road Accident Fund

For further benefits please download the Sanlam Gap Retail Brochure for 2024.

Manual process

Seamless process

Medical event occurs

Medical event occurs

Medical provider submits claims to medical scheme for payment

Medical provider submits claims to medical scheme for payment

Medical scheme assesses claims and identifies shortfalls

Medical scheme assesses claims and identifies shortfalls

Member receives statement noting payment shortfalls, requiring payment

Member receives statement noting payment shortfalls, requiring payment

Member completes paperwork and submits to Sanlam Gap (sanlamclaims@kaelo.co.za)

Paperwork is received by Sanlam GAP and assessed, according to the policy benefits

Member does not complete ANY PAPERWORK as all information is automatically sent by the medical scheme directly to Sanlam Gap for assessment, according to the policy benefits

Once all documentation is received, claims shortfalls are paid within 7 to 14 working days

Claims shortfalls are paid within 7 to 14 working days

Member is paid and send a statement as confirmation

Member is paid and send a statement as confirmation

For further information please download the Sanlam Gap Seamless Claims Process.

Benefits

Casualty illness
Benefits relating to this clause will only be paid in respect of Emergency outpatient services that are provided within a casualty ward of a hospital. The Benefit is only payable in the event of after-hours Treatment in an Emergency situation.

After-hour emergency illness only at a Mediclinic for all Insured Parties covered (Mondays to Fridays: 6pm – 8am. All-day Saturdays, Sundays & public holidays).

Subject to a maximum of two such events per Annum and a maximum of R2650 per Insured Event.

Specialist benefit
Specialist Benefit - Out-of-hospital.

This Benefit will become payable when your Medical Scheme has paid a portion of your out of hospital specialist claim. We will cover the shortfall thereof.

Up to R5 200 per Insured Party per Annum, subject to the Overall Annual Limit.

Private ward
Cover for the difference between the cost of a general ward and a private ward. Payable only in the event of confinement (childbirth) admissions. Only at a Mediclinic hospital (if available).

Subject to a maximum of one event per Insured Party per Annum and a maximum of R5 200 subject to the Overall Annual Limit.

Cancer lump sum pay out
The benefit payable is equal to the monthly medical scheme and gap contribution applicable after the qualifying event, multiply by six and subject to an overall annual limit. This benefit is limited to one event over the policy lifetime.

Benefit is limited to one claim per Insured Party and is only payable on first-time diagnosis as a lump sum of R10 600.

Cashless co-payment
Benefits relating to this clause will only be paid in respect of defined diagnostic procedures that occurred during an
Insured Event.
The Benefit payable is equal to the fixed value Deductible or Co-payment amount, as defined in the rules of the Insured Party's Medical Scheme.
Benefit is directly payable to the Mediclinic Pre-authorisation letter required.

Unlimited subject to the Overall Annual Limit.
Only at a Mediclinic facility.

Cashless penalty co-payment
Notwithstanding exclusion related penalties, the Insurer will pay a fixed value Penalty Co-payment or Deductible, or a percentage Penalty Co-payment that does not exceed 30%, for the voluntary use by an Insured Party of a Mediclinic facility that is not part of their Medical Scheme Hospital Network.

Unlimited only at a Mediclinic facility subject to a maximum of R17 500 per event and subject to the Overall Annual Limit.

For further benefits please download the Sanlam Gap Cover Mediclinic Extender brochure.

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Sanlam Comprehensive Gap Cover Plan Individual or family monthly premium.

  • Single
  • Families

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