SANLAM GAP COVER 2021
Transcript of 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
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)
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.
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.
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
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.
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.
2021 SANLAM COMPREHENSIVE GAP
Please refer to the Sanlam Gap Cover brochure and policy document, for more detailed information.
* 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
Please refer to the Sanlam Gap Cover brochure and policy document, for more detailed information.
* 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.
Please refer to the Sanlam Gap Cover brochure and policy document, for more detailed information.
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
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)
questions
thank you