SANLAM GAP COVER 2021

SANLAM GAP

COVER 2021

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.

Kaelo Risk(Pty)Ltd is an authorised financial services provider (FSP 36931)

Insurance Products are underwritten by Centriq Insurance

Company Limited ("Centriq") a licensed non-life insurer and authorized Financial Services Provider (FSP 3417)

From as little as R219 for an individual member and R385 for a

family, per month

You may think that if you have medical aid you’re fully

covered for all in-hospital expenses but more often than

not, this isn't the case.

There is often a large (and very costly) difference

between what a specialist charges in hospital and what

your medical scheme will cover - and it's up to you

to pay the shortfall.

Sanlam Gap Cover will help to protect against funding these

unforeseen expenses from your own pocket.

Sanlam Gap Cover

Comprehensive Cover made simple for you.

Sanlam Gap Cover makes things even

easier by offering comprehensive cover.

No complicated tiers.

No confusing options.

Purpose is at the heart of everything

we do





Company Limited ("Centriq") a licensed non-life insurer and authorized Financial Services Provider (FSP 3417)

SANLAM GAP RETAIL RATES FOR 2021

Younger than 60 years Older than 60 years

Individuals younger than 60 years

R 219.00

Families younger than 60 years

R 385.00

Individuals older than 60 years

R 438.00

Families older than 60 years

R 767.00

Sanlam Gap Benefits

Core Benefits

The following Benefits are defined as

Core Benefits:

• Tariff Shortfalls

• Co-Payments and Deductibles

• Shortfalls from Sub-Limits

• Oncology Tariff Shortfalls

• Oncology Sub Limits and co-payments

• Out of hospital Tariff Shortfalls

• Accidental Casualty

• Penalty Co-Payment

• Innovative Medicines

Overall annual limit R172 000 per insured per annum (per person on Sanlam Gap cover)

2021 SANLAM COMPREHENSIVE GAP

Please refer to the Sanlam Gap Cover brochure and policy document, for more detailed information.

Overall limit of R172 000 per member per year as per regulations.

Hospital Tariff ShortfallsAdditional 500% of Medical Scheme Tariff,

Shortfalls up to R172 000 per insured per annum

Co-payments Deductibles

Defined Rand Value Diagnostic procedures.

Such as MRI & CT Scans, Colonoscopy etc

Innovation Medicines

Charges relating to the service supplied which has exceeded a relevant

Benefit sub-limit. Limited to R55 220 per event

A value equal to the lesser of 25% of the total drug cost or R10 000 as it

relates to Innovative drugs.




Shortfalls from Sub-Limits

Oncology Tariff Shortfalls

and Sub-Limits

Annual limit on oncology treatment and the benefit has been exhausted,

full cover up to R172 000 per insured per annum

Oncology Co-payments The maximum Benefit payable shall be limited to a 20% Co-payment

Defined Out-Patient Procedures and Treatments

Such as:

Surgical extraction of Wisdom TeethHome Births

Dialysis Treatment

Circumcision

Cone Biopsy

Pap Smears

Gastroscopy

Colonoscopy

General Surgery

Breast Biopsies

For the full list please access our Sanlam Gap brochure




Out-of-Hospital Tariff

Shortfalls

Accidental Casualty

Subject to a maximum of R15 600 per event

Cover for all services delivered in the casualty ward relating to an accident

even if the costs are paid from the Medical Savings Account

Penalty Co-Payment

Subject to a maximum of one such event per Family per annum and a

maximum of R15 800 per event or a percentage penalty co-payment that

does not exceed 30% for the voluntary use of a non network Hospital.



* Accident – Bodily injury caused by violent, unintentional, external and physical means.

Sanlam Gap Benefits

Benefit Extender

Please be aware that the following benefit extenders

do not form part of the overall annual limit of R172 000

The following Benefits are defined as the Benefit Extender:

• Family Booster

• Hospital Booster

• Family Protector

• Dental Benefit

• Medical Scheme and Gap premium waiver

• RAF Claims

Family Booster A lump sum Benefit of R14 000 is payable when a Premature Birth occurs.

Payable when the insured is admitted to a Hospital as a direct result of

Accidental Harm or Premature Birth.

R400 per day from the 1st to the 13th day (inclusive)

R780 per day from the 14th to the 20th day (inclusive)

R1 560 per day from the 21st to the 30th day (inclusive)

A maximum of two Hospital Episodes per Family will attract Benefits under

this clause per annum, subject to an overall maximum Benefit of

R26 260 per Insured Party per annum.

No benefit payable after Day 30.

2021 BENEFIT EXTENDER

Hospital Booster


* Premature Birth – More than 41 days before the originally expected birth date of 40 weeks.

2021 BENEFIT EXTENDER

Family Protector

The lump sum Benefit is payable upon the Death or Permanent Disability

of an Insured Party due to Accidental Harm.

Children below six years R20 000

All other insured parties R30 000

Medical Scheme and Gap

Premium Waiver

The lump sum Benefit is payable upon Accidental and Oncology treatment

that occurred after date of inception. Max 2 events per family per year.

R49 900

Dental Reconstruction

A lump sum Benefit payable upon the death or permanent disability of the

Principal Member of the Medical Scheme as a result of an Accident.

Multiplied by six and subject to an overall maximum limit of R34 815.

This benefit is limited to one event over the policy lifetime.


RAF Claims

An end-to-end service is provided by the nominated service provider of

Kaelo, to assist Insured Parties with legitimate claims against the Road

Accident Fund.

FREQUENTLY ASKED QUESTIONS:

Questions Answers

Can my family (principal member, partner/spouse and

children up until they reach the age of 27) be on more than

one medical aid scheme under one Sanlam Gap policy?

Yes.

Please be aware that since 2020 financially dependent

parents were required to be on their own gap policy

How long do I have to submit my Gap cover claim? 6 months from the insured event

How long does the principal member have to register/add a

new born onto Sanlam Gap Cover, without any underwriting

imposed?

90 Days from date of birth

Will Sanlam Gap cover planned PMB procedures? Yes PMB conditions are covered where the scheme has paid

up to their maximum scheme rate, limited to an additional

500% and subject to clinical review by MedClaim assist.

How does Sanlam Gap collect premiums In Advance OR Arrears

This is dependent on the strike date chosen.

1st,7th,15th is collected in advance

25th, 31st is collected in arrears

Compulsory membership:

No waiting periods, staff get to enjoy full cover from their date of joining.

Voluntary Group membership:

This is similar to retail/individual underwriting. Full underwriting will be imposed, a 3 month general waiting

period and a 12 months pre-existing exclusion for conditions incurred prior to joining Sanlam Gap (conditions

incurred after join date will be covered)

For staff members that can supply proof of previous gap coverage for 12 months or longer prior to joining

Sanlam Gap no underwriting will be imposed. We will require proof of coverage with a join and end date of the

certificate.

For staff members that may be on another gap cover for less than 12 months, then the difference will be

imposed (of the 12 month pre-existing waiting period)

If a staff member resigns from their company, and wishes to continue with Sanlam Gap they will be required to

complete a new application form and the retail rates will apply.

SANLAM GAP UNDERWRITING

SANLAM GAP

Premium Payment:

Payment Terms: In Advance OR Arrears (This is dependent on the strike date

chosen. 1st,7th,15th is collected in advance & 25th, 31st is collected in

arrears)

Sanlam Gap will terminate a members policy should they not receive

premiums after the 3rd consecutive month.

Termination notice period:

31 days notice to terminate your Sanlam Gap policy

TREATMENTS NOT PAID FOR BY SANLAM GAP

Specialized dentistry and treatment, such as Crowns, Implants, Bridges etc (except surgical

wisdom teeth extraction)

Cosmetic surgery.

Claims older than 6 months.

Any claim that is excluded or rejected by the Insured's medical scheme.

Day-to-day claims, unless otherwise specified.

Claims not approved by, excluded by or paid as an ex-gratia by the medical scheme.

Mental institutions are not covered (example: Treatment for Depression)

Please refer to the Sanlam Gap Policy Document for the full list of exclusions.

Should Kaelo Risk request a medical examination, this will be paid for by Kaelo Risk.

SANLAM GAP SERVICE LEVELS

Innovative solutions

Sanlam Gap provides you with competitive group/company pricing

Assistance with corporate company presentations and monthly help desks

A dedicated client relationship manager in the various regions

Mid year campaigns within existing companies

Broker campaigns

Online and Mobile friendly application form





Company Limited ("Centriq") a licensed non-life insurer and authorized Financial Services

Provider (FSP 3417)

questions

thank you

SANLAM GAP COVER 2021

Documents

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