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Sanlam Medical Gap Cover Insurance

From only R198 per month, Sanlam Medical 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 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.

How it Works

How medical gap cover
insurance works.

View FAQ

View the Frequently
Asked Questions.

Plan Details

Find out more about
Sanlam's Comprehensive Gap Cover Plan.

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From only R198 per month.

How Medical Gap Cover Insurance Works

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

Frequently Asked Questions

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.

Sanlam Comprehensive Gap Cover Plan

Individual or family monthly premium:

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

Benefits

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

Up to 5-times medical aid tariff

Sub-Limits
A sub-limit is a limit within the amount of cover that your medical aid provides, for a specific in-hospital event or procedure. This means that should the cost for a certain procedure exceed the applicable limit, you will be liable to pay the shortfall.

R40 000 per event/condition

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

Unlimited cover for specified procedures

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

Unlimited cover for specified procedures

Penalty Co-Payment

1 per family per annum (maximum R12 000)

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 5 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 R150 000 per insured per annum

Emergency 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.

Up to R12 000 per event (max R20 000 pa)

Benefits

Hospital Cash Benefit
A cash payment you receive for every day you spend in hospital due to an accident or premature birth (6 weeks or earlier).

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

R 300 per day: Day 1 to 13
R 600 per day: Day 14 to 20
R1 200 per day: Day 21 to 30
Maximum of R20 000 per beneficiary per annum

Premature Birth
When a baby is born earlier than 34 weeks into a pregnancy.

R12 000 per event

Death/Permanent Disability
A single per member payment if the member dies or is disabled and unable to work in the given profession.

Illness: R12 000 per member
Accidental: R24 000 per member

Medical Scheme Premium Waiver
Your medical aid payments will be covered for your family for up to six months up to a maximum of R4 000 per month in the event of death or permanent disability.

6 months – Max R4 000 per month

Dental Reconstruction
Dental work in the event of trauma or cancers and tumours. Cosmetic work is excluded.

Up to R36 000 per event/condition

Road Accident Fund Claims (RAF)

End-to-end legal assistance in RAF Claims
(100% RAF Benefit Allocation to Claimant)

Sanlam Reality members on the Reality Plus and Reality Health membership options can get discounts of up to 30% on qualifying risk products. For more information on how to join, visit the Sanlam Reality website.

Benefits

Comprehensive Gap Cover

Hospital Cash Benefit (only payable for accidents and premature births – 6 weeks or earlier, subject to a maximum of R20 000 per beneficiary per annum)

The enhanced benefits below are only available to Sanlam Reality Members.

R 600 per day: Day 1 to 13
R1 200 per day: Day 14 to 20
R1 800 per day: Day 21 to 30

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The Sanlam Comprehensive Gap Cover Plan covers the primary member and all dependants on your medical aid at the point of claiming.

  • 0-59 years R198pm
  • |
  • 60+ years R400pm

Limit on Gap Cover Insurance Benefits

New regulations for gap cover stipulate that:

  • From 1 April 2017 any new policyholders will only be able to claim R 150 000 per year, for every insured individual on the policy. However, all existing gap cover policyholders, or anyone who takes out medical gap cover insurance up till 31 March 2017, will only be affected by this limitation of benefits from 1 January 2018.
  • The annual R 150 000 limitation per insured person, will not result in a reduction of premiums for existing gap cover policy holders.
  • Hospital cash-back plans will be limited to paying their clients a maximum of R3 000 per day, or a total lump sum of R20 000 per year, also either from 1 April 2017, or 1 January 2018, depending on whether you are a new policyholder or an existing one.

Contact Us

Tel: 0860 000 952

After submission of these forms, you will be contacted within 48 hours by Completemed.

Completemed Healthcare Consultants (Completemed) is an authorised FSP (FSP 3373), a full subsidiary of Sanlam Life

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