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

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

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

Penalty co-payment

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.

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.

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.

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.

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.

Family Protector
The lump sum benefit is payable upon the death or permanent disability of an insured party due to accidental harm.

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.

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.

Manual process

Medical event occurs

Medical provider submits claims to medical scheme for payment

Medical scheme assesses claims and identifies shortfalls

Member receives statement noting payment shortfalls, requiring payment

Member completes paperwork and submits to Sanlam Gap (sanlamclaims@kaelo.co.za)

Paperwork is received by Sanlam GAP and assessed, according to the policy benefits

Once all documentation is received, claims shortfalls are paid within 7 to 14 working days

Member is paid and send a statement as confirmation

Casualty illness
Benefits relating to this clause will only be paid in respect of Emergency outpatient 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-hour emergency illness only at a Mediclinic for all Insured Parties covered (Mondays to Fridays: 6pm – 8am. All-day Saturdays, Sundays & public holidays).

Specialist benefit
Specialist Benefit - Out-of-hospital.

This Benefit will become payable when your Medical Scheme has paid a portion of your out of hospital specialist claim. We will cover the shortfall thereof.

Private ward
Cover for the difference between the cost of a general ward and a private ward. Payable only in the event of confinement (childbirth) admissions. Only at a Mediclinic hospital (if available).

Cancer lump sum pay out
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.

Cashless co-payment
Benefits relating to this clause will only be paid in respect of defined diagnostic procedures that occurred during an
Insured Event.
The Benefit payable is equal to the fixed value Deductible or Co-payment amount, as defined in the rules of the Insured Party's Medical Scheme.
Benefit is directly payable to the Mediclinic Pre-authorisation letter required.

Cashless penalty co-payment
Notwithstanding exclusion related penalties, the Insurer will pay a fixed value Penalty Co-payment or Deductible, or a percentage Penalty Co-payment that does not exceed 30%, for the voluntary use by an Insured Party of a Mediclinic facility that is not part of their Medical Scheme Hospital Network.