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Sanlam Medical Gap Cover Insurance

From R200 for individuals, and R352 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 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 Comprehensive Gap Cover Plan.

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From R200 for individuals, and R352 for families.

Ranked as 2018 leading Gap Cover provider for
under 60-year-olds.

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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.

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 (excluding financially dependent parents).

Yes, the following waiting periods apply:

  • A general waiting period of 3 months on all benefits.
  • A 12 months condition specific for pre-existing conditions for which you received advice, treatment or diagnosis 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).
  • 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.
  • Any claim that is excluded or rejected by the Insured’s medical scheme.

Comprehensive Medical Gap Cover

  • Individuals
    0-59 years R200pm
    60+ years R400pm
  • Families
    0-59 years R352pm
    60+ years R700pm

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:

  • 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.

Sanlam Comprehensive Gap Cover Plan

2020 Benefits

Individuals 59 years and younger
R200.00*
Families 59 years and younger
R352.00*
Individuals 60 years and older
R400.00*
Families 60 years and older
R700.00*

Benefits

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.

R52 100 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 R15 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 R165 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 000 per event

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 380 per day: Day 1 to 13
R 750 per day: Day 14 to 20
R1 500 per day: Day 21 to 30
Maximum of R25 190 per beneficiary per annum

Premature Birth
More than 6 weeks before due date.

R14 000 per event

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

Accidental: R28 000 per member

Medical Scheme and the Sanlam Gap Policy Premium Waiver
Your medical aid payments will be covered for your family for up to six months up to a maximum of R5 500 per month in the event of death or permanent disability of the principal member.

6 months – Max R5 500 per month

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

Up to R48 000 per event/condition

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.

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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.

  • Individual
    0-59 years R200pm
    60+ years R400pm
  • Families
    0-59 years R352pm
    60+ years R700pm

Limit on Gap Cover Insurance Benefits

New regulations for gap cover stipulate that:

  • Policyholders will only be able to claim R165 000 per year, for every insured individual on the policy
  • Hospital cash-back plans will be limited to paying their clients a maximum of R25 190 per year

Contact Us

Tel: 0861 111 167

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.

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