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Sanlam Medical Gap Cover Insurance
Sanlam Gap Cover Insurance provides for the difference between what your medical aid pays and the rates charged by medical specialists.
From R320 for individuals, and R485 for families
Sanlam Gap Comprehensive at an additional 600% above medical scheme rates for tariff shortfalls
Sanlam Gap Comprehensive unlimited diagnostic co-payments up to the overall annual limit of R210, 580.
How it works
The value of gap cover
In certain cases the cost for in-hospital procedures or outpatient treatment may exceed the base medical aid rate by an additional five 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.
Note: Graph values show actual payments made by medical aid schemes and gap cover amounts paid.
Plan options
Find the right plan suited to your needs.
- For individuals
- For families
Individuals under 60 years
FROM
R320/pm
Individuals 60+ years
FROM
R832/pm
Families (main member under 60 years)
FROM
R485/pm
Families (main member 60+ years)
FROM
R999/pm
2025 BENEFITS
Sanlam Comprehensive Gap Cover Plan
New regulations for gap cover stipulate that:
Policyholders will only be able to claim R210,580 per year, for every insured individual on the policy
Hospital Booster benefits up to a maximum of R29,300 per year
The Sanlam Gap Retail Brochure for 2025 contains full list of benefits and conditions.
- In-hospital benefits
Tariff shortfalls: Additional six-times (600%) of medical scheme tariff
Sub-limits: R66,400 per event/condition
Co-payments: Unlimited up to the overall annual limit.
Deductibles: Unlimited up to the overall annual limit.
Penalty co-payment: A maximum of two 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.
- Out-of-hospital benefits
Co-payments: MRI/CT scans: Unlimited. Oncology sub-limits: Limited to statutory maximum of R210,580 per insured per annum.
Accidental Casualty Benefit: Subject to a maximum of R18,450 per event.
Child Casualty Benefit: Subject to a maximum of two such events per annum and a maximum of R3,000 per event. Limited to children under age 12.
- Additional benefits
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 Booster: Lump sum Benefit is R16,400.
Family Protector: Limited as follows: Children below six years: R20,000. All other insured parties: R30,000.
Medical scheme and the Sanlam Gap Policy contribution waiver: The benefit payable is waivered for a period of 6 months to an overall maximum limit of R40,000.
Dental reconstruction: 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.
- Seamless claims 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 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
Claims shortfalls are paid within 7 to 14 working days
Member is paid and send a statement as confirmation
- Mediclinic Extender
Casualty illness: Subject to a maximum of two such events per Annum and a maximum of R2800 per Insured Event.
Specialist benefit: Up to R5 200 per Insured Party per Annum, subject to the Overall Annual Limit.
Private ward: 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 out: Benefit is limited to one claim per Insured Party and is only payable on first-time diagnosis as a lump sum of R10 900.
Cashless co-payment: Unlimited subject to the Overall Annual Limit. Only at a Mediclinic facility. Penalty co-payments, limited to two events up to R17,500 per event.
WHAT TO LOOK FOR
Frequently asked questions
- Why do I need gap cover?
In certain cases the cost for in-hospital procedures or outpatient treatment may exceed the base medical aid rate by six 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.
- Do I qualify for gap cover?
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 two medical aids will be covered by a single Sanlam Gap Cover policy.
Special dependants may be included (excluding financially dependent parents).
- Are there any waiting periods?
Yes, the following waiting periods apply:
A general waiting period of three 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 2025 (Section H) for more information.
- What treatments are not paid for by gap cover?
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 Sanlam Gap Cover Comprehensive Plan in the event of trauma, cancers and tumours.
Claims older than six months.
Any claim that is excluded or rejected by the insured’s medical scheme.
Please refer to our Policy Document for 2025 (Section I) for more information.
- How much does gap cover cost?
Under 30 Single R320pm Families R485pm
30 - 45 Single R444pm Families R540pm
45 - 60 Single R495pm Families R582pm
Over 60 Single R832pm Families R999pm
Speak to an expert
Navigating life and all its decisions can sometimes be daunting. You can do it on your own if you want to, or you can rely on one of Sanlam’s expert financial advisers to ensure you get the right financial advice.
Statutory notice : This is not a Medical Scheme and the cover is not the same as that of a Medical Scheme. This policy is not a substitute for Medical Scheme membership. AfroCentric Health (RF) (Pty) Ltd holds preference shares in Centriq Insurance Company Limited. Insurance Products are insured by Centriq Insurance Company Limited (“Centriq”) a licensed non-life insurer and authorised Financial Services Provider (FSP 3417).