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Sanlam Medical Gap Cover Insurance

From R166 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.

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From R166 monthly
contribution.

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. All family members must belong to the principal member’s medical scheme and must be registered on the same medical scheme benefit option.
  • The maximum entry age is 60.
  • 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.
  • 12 months for maternity benefits.
  • Permanent exclusions may apply.
  • 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).
  • 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.
  • Standard Medical Aid Gap Cover - R166 per month
  • Comprehensive Medical Gap Cover - R198 per month

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 Gap Cover Plans

Comprehensive Plan

R198

Individual or family monthly premium

Tariff Shortfalls

Up to 5-times medical aid tariff

Sub-Limits

R40 000 per event/condition

Co-Payments

Unlimited cover for specified procedures**

Deductibles

Unlimited cover for specified procedures**

Penalty Co-Payment

1 per family per annum (maximum R12 000)

Tariff Shortfalls

Up to 5-times medical aid tariff

Co-Payments
  • MRI/CT Scans
    Unlimited
  • Oncology
    R325 000 per treatment cycle per beneficiary
Emergency Casualty Benefit

Up to R12 000 per event

Hospital Cash Benefit

R   600 per day - Day    7 to 13
R1 200 per day - Day 14 to 20
R1 800 per day - Day 21 to 30

Premature Birth

R12 000 per event

Death/Permanent Disability

Illness        - R12 000 per member
Accidental - R24 000 per member

Medical Scheme Premium
Waiver

6 months - Max R3 600 per month

Dental Reconstruction

Up to R36 000 per event/condition

Road Accident Fund (RAF)

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

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Standard Plan

R166

Individual or family monthly premium

Tariff Shortfalls

Up to 5-times medical aid tariff

Sub-Limits

R20 000 per event/condition

Co-Payments

No benefit

Deductibles

No benefit

Penalty Co-Payment

No benefit



Tariff Shortfalls

No benefits

Co-Payments
  • MRI/CT Scans
    No benefits
  • Oncology
    No benefits

Emergency Casualty Benefit

Up to R9 500 per event

Hospital Cash Benefit

R300 per day - Day   7 to 13
R600 per day - Day 14 to 20
R900 per day - Day 21 to 30

Premature Birth

R9 000 per event

Death/Permanent Disability

Illness        -   R9 000 per member
Accidental - R18 000 per member

Medical Scheme Premium
Waiver

6 months - Max R3 300 per month

Dental Reconstruction

No benefits

Road Accident Fund (RAF)

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

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

Reality Members

If you are a Sanlam Reality member on any of the Reality membership options, you qualify for a free hospital cash benefit that pays out from the third day of hospitalisation instead of the seventh day, which is standard practice. Speak to an adviser and find out more.

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Tel: 0860 473 223

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