Gap Insurance for Medical Expenses by Sanlam

December 14, 2021

What medical expenses gap insurance product does Sanlam offer?

  • Sanlam offers comprehensive gap cover.
  • A gap policy comes with low monthly premiums
  • Gap cover pays the difference between what your medical aid pays and what you are charged.
  • The difference can be quite substantial.

Medical Expenses and Sanlam

Sanlam Medical Gap Cover offers an affordable way to ensure yourself against shortfalls in medical expenses. Contrary to popular belief, medical aids seldom pay the full costs associated with hospitalization.

This is because the hospitals seldom charge the base medical aid rate. So, even if your medical aid pays 100% of the base medical rate, you might still come up short. Some hospitals and medical specialists can charge up to five times more than the base medical rate.

Why Get Gap Cover?

Gap cover pays the excess not covered by your medical aid.

Would I Qualify for Gap Cover?

If you are already a member of a medical aid scheme registered in South Africa, you should qualify.

Who is Covered?

Gap Insurance for Unexpected Medical ExpensesYou, your spouse and children that are 26 and younger will be covered by your policy. You may apply for special dependents to be added as well.

If you have two different medical aids for the family, you will still only be covered by a single Gap policy.

Is Cover for Medical Expenses Immediate?

Full cover will come into place once a 3-month waiting period has elapsed.

If you have a pre-existing condition, that required medical advice in the 12 months before you took the policy, you will need to wait 12 months for cover for that condition.

Are Some Treatments Excluded?

There are treatments that do not fall under the auspices of gap cover as follows:

  • Obesity treatments, such as stomach stapling
  • Elective cosmetic surgery. (Surgery needed because of trauma or resulting from a cancer treatment are not considered elective cosmetic surgery.)
  • Co-payments expressed as a percentage instead of a Rand amount. This does not apply when it comes to oncology.
  • Penalties or co-payments that arise as a result of not following the scheme’s rules.
  • Dentistry of a specialized nature is excluded unless as a result of cancer or trauma.
  • Claims over 6 months old.


The Cost of Gap Cover

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 or read more here 

How to Claim for Shortfall Medical Expenses

Xelus Pty (Ltd) administers claims on behalf of Sanlam. Claims must be submitted in writing and can be emailed or faxed through. The claim form can be downloaded online and you can contact the call centre on 0861 11 11 67 if you need assistance.

You will also need to provide:

  • Your medical aid’s claim transaction remittance showing how much they paid.
  • The accounts that you are claiming for.
  • The account from the hospital, with details of your stay and the ICD codes.
  • An up to date medical aid membership certificate.


Next step: complete the form on this page, then click the Get a Quote button to get a personalised gap insurance quotation.


All info was correct at time of publishing