Comprehensive Gap Cover for Medical Aid in South Africa

December 14, 2021

Looking for comprehensive gap cover? Sanlam offers one of the best plans around with real value for money.

With a low monthly premium, a trip to the hospital is not going to leave you short. Or looking for extra cash to cover the amounts not paid by your medical aid.

Your medical plan pays 100% of medical aid rates for your hospital stay, but not all specialists or hospitals charge medical aid rates. In fact, some charge as much as five times over this. Which means that you are liable for the rest of the money.

Here’s where comprehensive gap cover comes to the rescue

Comprehensive gap

Comprehensive gap cover will pay the difference between what your medical aid pays and what the procedure actually costs.

It’s not something that we like to consider – after all, what are the chances that we will end up in a hospital?

But what if you do? Would you be able to pay the outstanding amount? Even if they only charge double, that still leaves you to find at least the amount that the medical aid paid. For a hospital stay, that could run in to thousands.

You should qualify for cover if you meet these requirements:

  • Only a member of a registered medical aid plan can apply.
  • You must be 60 years old or younger.
  • Your wife/husband/dependents must on the same medical aid as you.
  • All your dependents should be 27 years old or younger.

What are the waiting periods before cover comes into effect?

  • No benefits paid out during the first three months
  • If you have any pre-existing conditions, you wait 12 months before being covered
  • Maternity benefits apply only after the first year of the policy
  • Individual assessment of cases, as there may be permanent exclusions put in place

Is There Anything Gap Cover Excludes?

  • Cosmetic surgery treatments that are optional. Cosmetic surgery is only covered if it is as a result of a traumatic experience or brought on by cancer.
  • Obesity treatments, including stomach stapling, etc.
  • Co-payments that are not a set amount and charged as a percentage of the costs.
  • Costs that arise due to an error on your part. For example, not acting by the medical aid’s rules and regulations.
  • Dentistry of a specific nature unless it is required as a result of trauma, tumours or cancer.
  • Any claims submitted more than six months after services rendered.

What Can I Expect to Pay?

Sanlam Gap Cover offers the Comprehensive Gap Cover at R252 (younger than 60 years) and R605 (60 years and older).  This includes in-hospital treatment and some out-of-hospital treatment benefits.  Enhanced hospital cash benefits are only available to Sanlam Reality members.

For more information on the list of additional benefits and exclusions please check out the PDF document at SPF757_Gap Cover_Top Performer May 2018

What is the Claims Process?

Xelus administers Sanlam Gap Cover, and so claims must go through them. You can either submit your claim online or arrange to have it mailed or delivered by hand. You will need, in addition to the completed claim form:

  • Receipt from your medical scheme showing the amount they paid on your bill that you are claiming against.
  • The hospital statement. This must include the first four pages where admission and discharge times, as well as the ICD codes, are displayed.
  • You need an up to date certificate of membership from your medical aid scheme.


To get a FREE medical gap cover quote, just complete and send the form on this page

All info was correct at time of publishing