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 email@example.com for any advice on the different gap cover options.
How Medical Gap Cover Insurance Works.
View the Frequently Asked Questions.
Choose the programme that suits your needs.
Protect yourself against unexpected excess payments.
Note:Graph values show actual payments made by medical aid schemes andgap cover amounts paid out by Kaelo Risk (Pty) Ltd (FSP:36931), the administrator for Sanlam Gap Cover.
Let us assist you in choosing the right cover for your needs. Please fill in your details below, and one of our consultants will call you.
Please complete the form to purchase Sanlam Gap Cover, and we’ll help protect you against unexpected excess payments.
New regulations for gap cover stipulate that:
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.
Yes, the following waiting periods apply:
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:
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:
An e-mail and SMS is sent to the member when:
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.
A maximum of two events are covered under this Benefit Per Annum and up to a maximum amount of R17,500 per event, subject to the Core Benefit Limit.
Tariff shortfallsThe difference between the specialist’s fee and the medical scheme tariff.
Additional six-times medical aid tariff
Sub-limitsA 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.
R64,500 per event/condition
Co-paymentsThe excess payable upfront to the hospital before treatment or a procedure.
Subject to the Key Benefit Limit
Deductibles A deductible is a co-payment payable by a member on admission to hospital.
A maximum of two such events are covered under this benefit per annum and up to a maximum amount of R18,550 per event, subject to the Key Benefit Limit.
For further benefits please download the Sanlam Gap Retail Brochure for 2024.
Co-payments The excess payable upfront to the hospital before treatment or a procedure.
MRI/CT scans: UnlimitedOncology sub-limits: Limited to statutory maximum of R198,660 per insured per annum
Accidental Casualty BenefitThe 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 R18,450 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 R2,860 per event. Limited to children under age 12
Hospital Cash BenefitA 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 R29,300 per annum. The benefit is payable from day one of the hospital episode: R480 per day from the 1st to the 13th day (inclusive). R860 per day from the 14th to the 20th day (inclusive). R1,700 per day from the 21st to the 30th day (inclusive). Max R29,300 per annum.
Family BoosterThe 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 R15,900.
Family ProtectorThe 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 waiverThe 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 Key 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
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 (firstname.lastname@example.org)
Paperwork is received by Sanlam GAP and assessed, according to the policy benefits
Member does not complete ANY PAPERWORK as all information is automatically sent by the medical scheme directly to Sanlam Gap for assessment, according to the policy benefits
Once all documentation is received, claims shortfalls are paid within 7 to 14 working days
Claims shortfalls are paid within 7 to 14 working days
Member is paid and send a statement as confirmation
For further information please download the Sanlam Gap Seamless Claims Process.
Casualty illnessBenefits 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).
Subject to a maximum of two such events per Annum and a maximum of R2650 per Insured Event.
Specialist benefitSpecialist 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.
Up to R5 200 per Insured Party per Annum, subject to the Overall Annual Limit.
Private wardCover 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).
Subject to a maximum of one event per Insured Party per Annum and a maximum of R5 200 subject to the Overall Annual Limit.
Cancer lump sum pay outThe 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.
Benefit is limited to
one claim per Insured
Party and is only
payable on first-time
diagnosis as a lump
sum of R10 600.
Cashless co-paymentBenefits relating to this clause will only be paid in respect of defined diagnostic procedures that occurred during an
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
Unlimited subject to the Overall Annual Limit. Only at a Mediclinic facility.
Cashless penalty co-paymentNotwithstanding 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
Unlimited only at a Mediclinic facility subject to a maximum of R17 500 per event and subject to the Overall Annual Limit.
For further benefits please download the Sanlam Gap Cover Mediclinic Extender brochure.
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