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.

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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.

Yes

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

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.

R15 800 or a percentage penalty co-payment that does not exceed 30%.