In certain cases the cost for in-hospital procedures or outpatient treatment may exceed the base medical aid rate by 5-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.

• You need to be an existing member of a registered medical aid scheme.
• Gap cover extends to the principal member, their spouse and children up to age 27. Families covered on 2 medical aids will be covered by a single Sanlam Gap Cover policy.
• Special dependents may be included.

Yes, the following waiting periods apply:

• A general waiting period of 3 months on all benefits.
• 12 months for pre-existing conditions for which you received advice or treatment during the 12 months prior to the cover commencing.

• Treatment for obesity, including bariatric surgery (stomach stapling).
• Treatment for cosmetic surgery unless necessitated by a trauma or as a result of oncology treatment (e.g. breast reconstruction following a mastectomy).
• Any co-payment that is not a defined rand amount (i.e. it is applied as a percentage). Please note that this excludes the oncology co-payment cover.
• Any penalty, co-payment or limit applied by a medical scheme for not complying with the benefit rules or authorisation procedures (e.g. non-authorisation of a hospital admission or where the member is covered on a network plan and makes use of a non-network facility).
• Specialised Dentistry is only paid for on the Sanlam Gap Cover Comprehensive Plan in the event of trauma, cancers and tumours.
• Claims older than 6 months.

Comprehensive Medical Gap Cover

• R198 per month (younger than 60 years old)
• R400 per month (60 years and older)

Claims are assessed by Xelus Pty (Ltd), the Sanlam Gap Cover administrator. Claims must be submitted within 6 months of an event.

Claim submissions can be sent to:
Email: sanlamclaims@xelus.co.za
Fax: 086 501 8521
Or contact Xelus at: 0861 11 11 67

Download claim form

We require the following documents from you to process your claim:

• Claims transaction remittance (receipt) from the medical scheme.
• Relevant doctors’ accounts.
• Hospital account (the first four pages showing admission/discharge times and ICD codes).
• Current medical scheme membership certificate (copy of the membership card is not accepted).

An e-mail and SMS is sent to the member when:

• The claim is captured.
• Outstanding documentation is requested (assuming you have not signed the authority form).
• The claim is authorised.

Please note that payments will be made directly into the principal member’s bank account. By law, service providers may not be paid directly.