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Sanlam Medical Gap Cover Insurance

From R233 for individuals, and R409 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 five 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.

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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.

2022 BENEFITS

Sanlam Comprehensive Gap Cover Plan

Individuals younger than 60 years
R233.00*
Families younger than 60 years
R409.00*
Individuals older than 60 years
R466.00*
Families older than 60 years
R815.00*

Benefits

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

Additional five-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.

R57,500 per event/condition

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

Subject to the Core Benefit Limit

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

Subject to the Core 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 R16,500 per event, subject to the Core Benefit Limit.

For further benefits please download the Sanlam Gap Retail Brochure for 2022.

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 R177,800 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 R16,500 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 R2,500 per event. Limited to children under age 12

For further benefits please download the Sanlam Gap Retail Brochure for 2022.

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 R27,690 per annum. The benefit is payable from day one of the hospital episode: R450 per day from the 1st to the 13th day (inclusive). R820 per day from the 14th to the 20th day (inclusive). R1,610 per day from the 21st to the 30th day (inclusive). Max R27,690.00 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 R15,000.

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 Core 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 2022.

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Sanlam Comprehensive Gap Cover Plan Individual or family monthly premium.

  • Individual
    0-59 years R233pm
    60+ years R466pm
  • Families
    0-59 years R409pm
    60+ years R815pm

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WHAT TO LOOK FOR

Frequently asked questions

In certain cases the cost for in-hospital procedures or outpatient treatment may exceed the base medical aid rate by five 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 until they reach the age of 27. Families covered on two medical aids will be covered by a single Sanlam Gap Cover policy.
  • Special dependants may be included (excluding financially dependent parents).

Yes, the following waiting periods apply:

  • A general waiting period of three 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.
  • Please refer to our Policy Document for 2022 (Section H) for more information.
  • 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 six months.
  • Any claim that is excluded or rejected by the insured’s medical scheme.
  • Please refer to our Policy Document for 2022 (Section I) for more information.

Comprehensive Medical Gap Cover

  • Individual
    0-59 years R233pm
    60+ years R466pm
  • Families
    0-59 years R409pm
    60+ years R815pm

Claims are assessed by Kaelo Risk (Pty) Ltd, the Sanlam Gap Cover administrator. Claims must be submitted within six 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.

Financially dependent parents will be required to take out their own gap policy as Sanlam Gap will only cover the principal member, partner/spouse and children (under the age of 27).

No, the supplementary benefits are additional benefits Sanlam offers their clients.

Six months from the insured event.

All the beneficiaries covered on the policy can claim for this benefit in the event of death or permanent disability due to accidental harm. Children below six years R20,000, all other insured parties R30,000.

No, only pre-existing conditions will be excluded for 12 months if the client did not have previous cover.

You have 90 days of which to add your baby onto your policy.

A maximum of two such events are covered under this benefit per annum and up to a maximum amount of R16,500 per event, subject to the Core Benefit Limit.

Limit on Gap Cover insurance benefits

New regulations for gap cover stipulate that:

  • Policyholders will only be able to claim R177,800 per year, for every insured individual on the policy
  • Hospital cash-back plans will be limited to paying their clients a maximum of R27,690 per year

Speak to an expert

Navigating life and all its decisions can sometimes be daunting. You can do it on your own if you want to, or you can rely on one of Sanlam’s expert financial advisers to ensure you get the right financial advice.

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