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In these trying economic times, you would definitely NOT want to end up in the unpleasant situation where your medical treatment costs more than the limit of your medical cover, right?

Without Medical Gap Cover, you would be personally liable for any payment shortfall that your medical scheme doesn’t cover.

Medical scheme benefits are limited to their Medical Scheme Tariffs (MST) and as we know, medical practitioners – Surgeons, Anaesthetists, Radiologists – can charge considerably more than the tariff rates.

Certain medical specialists have been known to charge up to four times the MST. This creates a shortfall — or gap — between the MST and the medical practitioner’s cost. Your medical scheme does not cover this, and you are liable for this amount. The actual cost of many procedures performed by surgeons, anaesthetists and other medical practitioners can add up to a sizeable payment gap.

“But we have a medical aid and I thought we were covered?”

“I have personal medical insurance so why would my costs not be covered?”

As a medical scheme member, you would probably expect your full costs to be covered if you are ever hospitalised. Unfortunately, this is seldom the case.

Outpaced by the private healthcare industry and associated procedures, the medical insurance companies are desperately trying to keep up with the spiralling healthcare industry charges. However, to achieve true parity, your medical insurance premiums (monthly policy payments), would cost significantly more than they do now.

This is a global phenomenon, and an issue that frustrates and causes understandable confusion. That is why you need to Investigate Medical Gap Cover quotes.

Just to be clear, any gap cover that you buy will not replace your regular medical aid cover as it only caters for its shortfalls. The good news is that you can belong to any medical scheme to benefit from the gap cover.

Where does this shortfall occur?

In current healthcare, the financial shortfall is between hospital charges and the NHRPL. This is what your medical aid ACTUALLY pays.

GAP cover pays YOU the financial difference between these two.

The National Health Reference Price List (NHRPL) is a pricing system maintained by the Department of Health and the Council for Medical Schemes. This results in Medical Scheme Tariffs (MST), as mentioned in the first paragraph.

The NHRPL specifies the rates to which your medical aid scheme must adhere. It is the amount of money that they are bound by law to pay out for a given situation. Doctors, hospitals and other medical service providers however, are not bound to these rates, and in fact charge up to 300% above these NHRPL prices. So, despite thinking you are financially covered for any medical eventuality in its entirety, for the most part you are not, and are often liable for an enormous shortfall.

Because gap cover is not medical aid, but an insurance-type solution designed to help you avoid unexpected payment shortfalls, you can be prepared against a wide range of potentially costly surprises.

Sanlam Gap Cover, not only covers shortfalls or gaps for medical practitioners in the event of hospitalisation involving surgery or medical treatment, but also certain procedures performed out-of-hospital.

So instead of using your personal funds / savings to bridge the shortfall between your medical aid and the cost of your treatment, you just file a claim from the insurance provider.

Why Sanlam Medical Gap Cover?

As with any other kind of insurance, there are several Medical Gap cover providers in South Africa

Sanlam is a differentiator and innovator, taking your financial security VERY seriously, and offers many products to assist you and your family, to ensure that you have peace of mind when you think of your future financial security.

South African National Life Assurance Company Limited has been around as an insurance firm for almost a century, and the firm is a leading insurer today.

In operation since 1918, this is a testimony to their long-term view of business and the specific needs of their policy holders.

Having weathered the ever-changing legislative challenges and the public having access to an increasing range of similar products, they continue to be highly successful thanks to their careful study of the constantly shifting trends, speedy adaptation to market challenges, and by truly providing for the needs of their most valuable asset – Their Clients!

Their medical gap cover product is yet another demonstration of how well Sanlam adapts to emerging changes in the medical industry.

Realising that the cost of local healthcare was constantly rising and that their medical insurance scheme subscribers were struggling to meet their healthcare costs, Sanlam developed a product to bridge this gap.

The research clearly showed that the cost of outpatient treatment and in-hospital stays could jump to as much as five times the medical cover limit of many providers.

Thus, Sanlam Medical Gap Cover was designed and offered, in order to ease the burden on families facing such bills by offering them Medical Gap Insurance.

The many reasons why you should consider Sanlam…

  • Cover extends to the principal member’s family, including their spouse and all children up to the age of 27.
  • Families covered on 2 medical aids will be covered by a single Sanlam Gap Cover policy.
  • Cover for family 60 years and older.
  • Special dependants, e.g. parents, who are covered on your medical scheme and are registered on the same medical scheme benefit option.
  • Tariff shortfalls – Additional 500% of scheme rate
  • Co-payments – Unlimited cover for specified procedures
  • Deductibles – Unlimited cover for specified procedures
  • Penalty co-payment – Max R12 800 cover per family per year
  • Sub-limits – R44 000 per event/condition

Out-Of-Hospital Treatment – 2018 Benefits:

  • Oncology co-payments – Limited to the statutory maximum of R150 000 per insured per annum
  • Oncology sub-limits – Limited to the statutory maximum of R150 000 per insured per annum
  • Out-patient treatment:
  • Co-payments – MRI/CT scans (unlimited)
  • 500% Tariff cover
  • Emergency Casualty Benefit (accidental only)

** Up to R12 000 per event (maximum 1 event per annum) **

Additional Features:

  • Hospital Cash Benefits
  • Premature Birth (More than 6 weeks before due date)
  • Death/Permanent Disability
  • Medical Scheme Premium Waiver
  • Dental Reconstruction (Trauma & Oncology)
  • 100% Road Accident Fund (RAF) claims


Tariff shortfall: The difference between the specialist’s fee and the medical scheme tariff.

Co-payment/Deductible: The excess payable upfront to the hospital before treatment or a procedure.

Qualifying Dependants: Spouse, children and special dependants registered on the principal member’s medical scheme.

So, with all this information and a little investigating from your side – you will soon be smiling again.

Sanlam is in the business of planning for tomorrow. Of safeguarding futures. And while we all wish we could be guaranteed a happy-go-lucky, trouble-free future, unfortunately challenges are bound to come our way.

Life’s biggest challenges often come in the form of poor health. And while no one can promise you a long, healthy life, Sanlam can promise you dependable support.

 Would You Like A Call-Back From The Guys At Sanlam Gap Cover?

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Until next time.

The InsuranceFundi Team


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