In certain cases the cost for in-hospital procedures or outpatient treatment may exceed the base medical aid rate by an additional 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 medical gap cover insurance works.
View the Frequently Asked Questions.
Find out more about Sanlam Comprehensive Gap Cover Plan.
From R219 for individuals, and R385 for families.
Note: Graph values show actual payments made by medical aid schemesand gap cover amounts paid out by Kaelo Risk (Pty) Ltd (FSP:36931),the administrator for Sanlam Gap Cover.
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.
Yes, the following waiting periods apply:
Comprehensive Medical Gap Cover
Claims are assessed by Kaelo Risk (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@kaelo.co.za Fax: 086 501 8521 Or contact Kaelo Risk at: 0861 11 11 67
Download claim form
We require the following documents from you to process your claim:
An e-mail and SMS is sent to the member when:
Please note that payments will be made directly into the principal member’s bank account.
Tariff Shortfalls The difference between the specialist’s fee and the medical scheme tariff.
Additional 5-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.
R55 220 per event/condition
Co-payments The excess payable upfront to the hospital before treatment or a procedure.
Unlimited up to the overall annual limit of R172 000 per insured party per annum
Deductibles A deductible is a co-payment payable by a member on admission to hospital.
Penalty Co-Payment
1 per family per annum (maximum R15 800)
Co-Payments The excess payable upfront to the hospital before treatment or a procedure.
MRI/CT Scans: Unlimited Oncology sub-limits: Limited to statutory maximum of R172 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 R15 600 per event
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.
R 400 per day: Day 1 to 13 R 780 per day: Day 14 to 20 R1 560 per day: Day 21 to 30 Maximum of R26 260 per beneficiary per annum
Family Booster The natural or surgically assisted birth of 1 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 mothers attending physician.
R14 000 per event
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 6 years: R20 000
All other insured parties: R30 000
Medical Scheme and the Sanlam Gap Policy Premium Waiver The benefit payable is equal to the monthly medical scheme and Gap contribution applicable after the qualifying event, multiply by 6 and subject to an overall annual limit. This benefit is limited to one event over the policy lifetime.
Subject to a maximum of R34 815 per event or medical condition
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.
This is subject to a maximum of two such events per Family per annum and a maximum of R49 900 per event.
Road Accident Fund Claims (RAF)
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.
New regulations for gap cover stipulate that:
After submission of these forms, you will be contacted within 48 hours by Sanlam Healthcare Consultants. Sanlam Healthcare Consultants is an authorised FSP (FSP 2759), a full subsidiary of Sanlam Life.