Any gap cover company can supply gap insurance to members of any medical aid in South Africa. However, Sanlam has set up a special relationship with Fedhealth and Bonitas to provide medical cover. that’s how you get gap cover for Fedhealth.
A gap policy covers the principal members and all dependents on the scheme.
Gap Cover for Fedhealth
Sanlam medical gap cover insurance provides for the difference between what your medical aid pays and the rates charged by medical specialists.
The gap is growing all the time. In certain cases, the cost of in-hospital procedures or outpatient treatment may exceed the basic medical aid rate by five times.
When you take out Sanlam medical gap cover for Fedhealth or any other medical aid, you ensure that you and your family do not have large excess amounts to settle.
The graph shows the difference between what medical aids will pay for certain procedures and the proportion that medical gap cover.
How to Qualify
- For Sanlam gap cover you must be younger than 60.
- You must be a member of a registered medical aid scheme in South Africa
- Gap cover applies to the primary member, the spouse and children up to the age of 27. Each family member must belong to the primary member’s medical scheme. They must also have the same medical aid benefit option.
- You can include special dependents on the policy.
Waiting Periods
Waiting periods do apply:
- A general waiting time of 3 months from inception of the policy on all benefits.
- Twelve months for pre-existing conditions, such as cancer.
- 12 months for maternity benefits.
Treatments that Sanlam Gap Cover Will Not Pay For
- Claims older than six months.
- Treatment for obesity, including bariatric surgery (stomach stapling).
- Any co-payment that does not have a rand amount (e.g. a percentage).
- Treatment for cosmetic surgery unless necessitated by trauma or as a result of oncology treatment (e.g. breast reconstruction following a mastectomy).
- Any penalty, co-payment or limit from a medical scheme for not complying with the benefit rules or authorisation procedures (e.g. non-authorisation of a hospital admission or where the member belongs to a network plan and makes use of a non-network facility).
- The Sanlam Gap Cover Comprehensive Plan pays for Specialised Dentistry only in the event of trauma, cancers and tumours.
Sanlam Premiums
Sanlam Gap Cover offers the Comprehensive Gap Cover. This includes in-hospital treatment and some out-of-hospital treatment benefits. Enhanced hospital cash benefits are only available to Sanlam Reality members.
How to Claim
Xelus Pty (Ltd), the Sanlam Gap Cover administrator, assesses claims. Submit the claim within six months of an event.
Send claim submissions to:
Email: claims@xelus.co.za
Fax: 086 501 8521
Or contact Xelus at: 0861 11 11 67
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 sufficient).
But if you sign an authority for Xelus to obtain the relevant claims information (on the claim form), they will obtain any outstanding supporting documents on your behalf. Sanlam pays claims daily.
The member will receive an e-mail and SMS 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. By law, service providers may not be paid directly.
To get a FREE medical gap cover quote, just complete and send the form on this page