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Gap Cover

Why Gap Cover is important

With medical scheme plans becoming more expensive and service providers starting to charge higher and higher rates, it makes sense to get an insurance product like gap cover that bridges the gap so you don’t end up being out of pocket. In essence, gap cover provides you with financial assistance on the portion of in-hospital specialist bills which your normal medical scheme doesn't cover.

Bear in mind that gap cover only pays for in-hospital care - not day-to-day medical expenses. If you’ve had to pay for hospital procedures and treatment in hospital, you’ll know that there’s often a big difference between the cost of treatment and what your medical scheme pays for. Gap cover helps you pay for the shortfall and ensures that you don’t suffer financially due to unexpected medical expenses.

Please contact Simeka Health on 0860 000 952 or email gapcover@simekahealth.co.za for any advice on the different gap cover options.

How it Works

How Medical Gap Cover Insurance Works.

View FAQ

View the Frequently Asked Questions.

Loyalty Programmes

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Protect yourself against unexpected excess payments.

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.

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

  • Individual
    0-59 years R219pm
    60+ years R438pm
  • Families
    0-59 years R385pm
    60+ years R767pm

Do you currently have Gap Cover?

Limit on Gap Cover Insurance Benefits

New regulations for gap cover stipulate that:

  • Policyholders will only be able to claim R 172 000 per year, for every insured individual on the policy.
  • Hospital cash-back plans will be limited to paying their clients a maximum of R26 260 per year.

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 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 2 medical aids will be covered by a single 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.
  • Please refer to our Policy Document for 2021 (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 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.
  • Please refer to our Policy Document for 2021 (Section I) for more information.

Contact us for a comparative quote

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.

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.

Yes, within the rules of your policy document.

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

Sanlam Comprehensive Gap Cover Plan

2021 Benefits

Individuals younger than 60 years
R219.00*
Families younger than 60 years
R385.00*
Individuals older than 60 years
R438.00*
Families older than 60 years
R767.00*

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.

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.

Unlimited up to the overall annual limit of R172 000 per insured party per annum

Penalty Co-Payment

1 per family per annum (maximum R15 800)

For further benefits please download the Sanlam Gap Retail Brochure for 2021

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 R172 000 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.

Up to R15 600 per event

For further benefits please download the Sanlam Gap Retail Brochure for 2021

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.

R 400 per day: Day 1 to 13 (inclusive)
R 780 per day: Day 14 to 20(inclusive)
R1 560 per day: Day 21 to 30(inclusive)
Maximum of R26 260 per insured party 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 Contribution 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.

For further benefits please download the Sanlam Gap Retail Brochure for 2021

Loyalty Programmes

Loyalty programmes normally offer a variety of rewards - ranging from lifestyle, wellness, cash- back rewards and discounts to financial education programmes. Choose the programme that suits your needs.

Discovery Vitality

Vitality is a wellness programme that helps you live a healthier, more rewarding life.

Benefits include:

  • Up to 100% off gym membership
  • Healthy foods cash-back rewards (up to R1000 cash back)
  • Half price movies – plus kids watch free before 19h00
  • Savings up to 35% on flights and holidays
  • Up to 35% off hotel accommodation
  • HealthyGear cash-back rewards
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Discovery Vitality

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Sanlam Reality

Sanlam Reality empowers and rewards you as you improve your financial wellbeing.

Benefits include:

  • Cash-back money saver cards
  • Discounted local and international flights
  • Free 1GB AlwaysOn Wi-Fi
  • Discount grocery coupons
  • Buy-1-get-1-free at Computicket
  • Discounted gym membership (60% - 80% on monthly fees)
  • Get personal services: personal assistant; Dial a teacher; legal assistance and trauma and medical assistance
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Sanlam Reality

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Momentum Multiply

Multiply is a wellness and rewards programme that inspires you to reach your goals.

Benefits include:

  • Up to R2 500 per family in Health Returns
  • Up to 60% off Myriad premiums
  • Discounted Mango flights up to 50%
  • Fixed 25% off gym fees
  • Discounted movie tickets
  • 50% off AVBOB funeral services
  • 25% off online shopping vouchers
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