How to make

a claim

Tel: 0861 11 11 67 • sanlamclaims@kaeloxelus.co.za • Fax: 086 501 8521

Dear Member,
In order for us to process your claim, we need you to please send the following documents to
sanlamclaims@kaeloxelus.co.za:

1. This completed and signed claim form

2. The relevant account from your doctor
3. The claims remittance from your medical aid
4. The hospital account (first 2-3 pages only). NB - If your claim only relates to a shortfall from a
surgeon/anaesthetist, we do not need this account.

Should anything be unclear or missing before we can finalise your claim, one of our consultants will contact you for
clarification.

If you have any queries please feel free to get in touch with us for clarification:

0861 493 587

General Enquiries • sanlaminfo@kaeloxelus.co.za • 48 hours TAT
Applications • sanlamapps@kaeloxelus.co.za • 7 working days TAT
Claims • sanlamclaims@kaeloxelus.co.za • 7 working days TAT
Escalations • escalations@kaeloxelus.co.za • 24 hours TAT

Kind regards
The Sanlam Gap Cover Team

Sanlam Gap Cover Underwritten by Centriq Insurance Company Limited. Administered by Xelus (PTY) LTD
 Claim Form
Tel: 0861 11 11 67 • sanlamclaims@kaeloxelus.co.za • Fax: 086 501 8521

Please complete in full and sign the declaration below

A Personal Details of Principal Member

(This must be the Sanlam Gap principal member)

Surname: ____________________________________________________ | First Name: ________________________________________________ |

ID Number: __________________________________________________ | Telephone: __________________________________________________|

Cell Phone: __________________________________________________ | e-mail: _____________________________________________________|

Employer Name: ______________________________________________ | Branch Name: _______________________________________________|

YYYY MM DD
Date of Employment: ___________/________/_______| Medical Scheme: _____________________________________________|

Membership Number: _________________________________________ | Name of current Benefit Option: _______________________________|

B Details of Patient & Service Providers

Patient's Surname: ____________________________________________ | First Name: _________________________________________________|

ID Number: __________________________________________________ | Hospital Admitted to: ________________________________________|

YYYY MM DD
Admission Date: ___________/________/_______| YYYY MM DD
Discharge Date: ___________/________/_______|

Nature of Illness or Condition: ______________________________________________________________________________________________________________________________________________________________________________________________________|

Procedure Performed: __________________________________________________________________________________________________________|

Name of Surgeon: ____________________________________________ | Practice No: _________________________________________________|

C Reimbursement Details (Principal Member’s Account Only)

Account Name: _______________________________________________ | Bank name: _________________________________________________|

Account Number: _____________________________________________ | Account Type: _______________________________________________|

Branch Name: ________________________________________________ | Branch Code: _______________________________________________|

D Declaration by Principal Member

I hereby declare that the details above as well as any supporting documentation supplied with this claim, are true and correct and I am aware

that any non-disclosure or misrepresentation may result in this claim being rejected or my policy being cancelled or voided from inception.

Signed: ______________________________________________________ | Full name: ___________________________________________________|

YYYY MM DD
Date: ___________/________/_______|

Sanlam Gap Cover Underwritten by Centriq Insurance Company Limited. Administered by Xelus (PTY) LTD
 Start

Member Once your claim has been received and

processed, a funding decision will be
communicated once assessed. Based on
the outcome of the funding decision,
After discharge from Hospital

Claims Process
funds are paid into your personal bank
and once your medical
account as provided in your
scheme has processed all the
claim/application form. Please note that
related accounts, KaeloXelus
we are not permitted by regulations to pay
members can submit a claim
providers directly.
for the shortfalls that may arise
on these accounts.
You are required to settle any outstanding
accounts directly with your doctor.

How to submit a claim

1. Complete the Sanlam

Claim Form

2. Obtain the required

documentation as outlined
on the claim form
On receipt of your claim, you will
Claims can be e-mailed to receive notification on receipt of
sanlamclaims@kaeloxelus.co.za your claim as well as updates
regarding the status of your claim.

Sanlam Gap Cover Underwritten by Centriq Insurance Company Limited. Administered by Xelus (PTY) LTD.