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Technical Guide 2015
Contents
1. Xelus – Structure & Background………………………………………..…..……..1
2. Sanlam – Comprehensive & Standard Gap Cover….……….…………..…...2
3. Supplementary Benefits…..……………………………………………………..….3
4. Terms & Conditions ………………………………………………………………….4
5. Waiting Periods & Underwriting …………………………...………………………4
6. Exclusions.……………………………………..……………………………..………..5
7. Application Procedure……………...………………………………………………6
8. Claim Procedure……………………..…………………………...…………….6 & 7
9. Contact Details……………………………………………………………………….8
1. Structure & Background
Below is an organogram of Sanlam/Xelus administration link:
Administrator
Xelus is registered with the Financial Services
Board as an underwriting manager (“UMA”)
and we distribute our products exclusively via
independent intermediaries.
In terms of a binder agreement, governed by
the Binder Regulations of the Short Term
Insurance Act, Centriq fully underwrites all our
insurance products.
We have invested in our staff and systems to
ensure efficient and prompt service levels. All
administrative functions are undertaken by
Xelus (i.e. premiums, claims, underwriting
etc.)
In 2013, Centriq achieved turnover is excess
of R2 billion and holds a very healthy
solvency ratio of 54%. Centriq is a wholly
owned subsidiary of Santam, the largest short
term insurance company in South Africa
2. Comprehensive & Basic Gap Cover
Sanlam offers two product solutions, namely Comprehensive Gap Cover and Standard Gap Cover.
These products are outlined below:
In – Hospital
Treatment
2015 Benefits
Sanlam
Standard Gap Cover
Tariff Shortfalls
Up to 500% of scheme tariff
Up to 500% of scheme tariff
Co-Payments
Unlimited
No benefit
Deductibles
Unlimited
No benefit
R33,000 pre event/condition
R13,000 per event/condition
R275,000 pbpa
Formulary on Biologicals: No
List of Defined Conditions: No
Includes pre-existing cancer: No
No benefit
Sub Limits
Oncology
Co-Payments
Out- of Hospital Treatment
Sanlam
Comprehensive Gap Cover
Out – Patient
Treatment
Co-Payments – MRI/CT scans
(unlimited)
500% Tariff Cover
Oncology, Dialysis, Surgical
Wisdom Extraction, Scopes &
Home Births (unlimited)
Emergency Casualty Benefit
(accidental only)
Up to R7500 per event (max
R15000 pa)
Emergency Casualty
Benefit (accidental only)
Up to R5000 per event
(max R10000 pa)
Important Notes:
1. In- Hospital Cover
All in-patient shortfall types are
covered (i.e. Tariffs, co-payments,
deductibles and sub-limits). The
benefit restrictions are 5x scheme
tariff shortfalls and R33, 000 per event
/condition where any type of limit or
sub-limit is applied. There is no rand
limit on co-payments and/or
deductibles.
2. Oncology Cover
Co-payments that are applied once a
pre-defined threshold is reached are
covered up to a maximum of 20% of
treatment cost. The annual limit is
R275, 000 pb per treatment cycle.
3. Out-of-hospital Tariff Shortfalls
Over and above oncology and
dialysis, this also provides tariff shortfall
cover on procedures that traditionally
are performed in a hospital or day
clinic (scopes/wisdoms/births) but if
performed on an out-patient basis will
not attract a co-payment/deductible
from the medical scheme. The benefit
is this designed to assist medical
schemes in managing overall costs by
using appropriate facilities. Sanlam
Comprehensive Gap Cover will cover
the tariff shortfalls in such instances.
3. Supplementary Benefits
The Benefit Extender is automatically included within the Sanlam Gap and does not require any
benefit choice or additional premium.
The intention is to provide financial protection in areas where indirect medical costs are incurred as
a result of the major events listed below:
2015 Benefits
Supplementary Benefits
Additional Cover
& Lump Sum
Benefits
Sanlam
Comprehensive Gap Cover
Sanlam
Standard Gap Cover
Hospital Cash Benefit
Day 7 to 13
R550pd
Day 14 to 21
R1100pd
Day 21 to 30
R1650pd
Hospital Cash Benefit
Day 7 to 13
R275pd
Day 14 to 21
R550pd
Day 21 to 30
R825pd
Premature Birth
(in 34th week or earlier)
R11,000 per event
Premature Birth
(in 34th week or earlier)
R8,250 per event
Death/Permanent Disability
Illness
: R11,000 pb
Accidental : R22,000 pb
Death/Permanent Disability
Illness
: R8,250 pb
Accidental : R16,500 pb
Dental Reconstruction
(Trauma & Oncology)
Up to R33,000 per event / condition
Medical Scheme Contribution Waiver
6 months – max R3300 pm
(principal member only)
Medical Scheme Contribution Waiver
6 months – max R3300 pm
(principal member only)
RAF Claims
End to end legal assistance in RAF
Claims (% RAF Benefit Allocation to
Claimant)
RAF Claims
End to end legal assistance in RAF
Claims (% RAF Benefit Allocation to
Claimant)
Important Notes:
1. The family booster and hospital
booster pay out on a per event basis,
e.g. if twins are born in the 32nd week,
only one benefit payment is made.
2. The dental reconstruction booster will
pay out up to R33, 000 per event /
condition. It applies to reconstruction
necessitated by oncology treatment
and/or a trauma (e.g. car accident)
that occurs after commencement of
the policy.
3. The medical scheme contribution
waiver only covers the principal
member of the Sanlam policy.
4. Terms & Conditions
The following Terms
important to note:
&
Conditions
are
Maximum entry age for individuals is 60
Maximum entry age for groups >20 is
65.
Waiting periods will be applied – see
member schedule or marketing offer
Cover applies to the member, spouse,
children (up to 26) and special
dependants covered under the
medical scheme
A spouse dependant on the medical
scheme can be the Sanlam Gap Cover
Principal member
Please refer to your policy document
for all conditions of cover
Important Notes:
1. The cover is applicable to the principal member, their spouse, children (up to age 26) and
special dependants that are covered on one registered medical scheme benefit option.
2. It is possible for a spouse dependant under the medical scheme to take up cover as the
Sanlam Gap Cover principal member. The same beneficiaries will be covered (the family
must all be on one registered medical scheme benefit option).
5. Underwriting & Waiting Periods
Medical Underwriting
Medical underwriting will be applied to all individual applicants.
The medical questionnaire completed on the application form will be taken into account for
Medical Underwriting.
Based on the completion of the above mentioned questionnaire the relevant application will either
be accepted or declined.
Non-disclosure of any medically relevant condition or past/future procedure which could result in
hospitalisation and/or surgery will be excluded from cover.
Waiting Periods
Standard waiting periods outlined below will be applied to all accepted policies”
3 months on all benefits
12 months on all pre-existing conditions
12 months on all claims relating to pregnancy, birth or confinement
6. Exclusions
A full list of the exclusion is contained within
Section D of the master policy document. The
pertinent areas that are worth noting in the
exclusions are:
Treatment for obesity which will
include bariatric surgery
Treatment for cosmetic surgery is
excluded unless necessitated by
trauma or as a result of oncology
treatment
Any co-payment that is not a defined
rand amount (i.e. it is applied as a
percentage) Please note that this
excludes the oncology co-payment
cover.
Any penalty, co-payment or limit
applied by the medical scheme for
non-adherence to the benefit rules or
authorisation procedures.
Dentistry is limited to basic dental
procedures. The in- hospital basic
dentistry that is covered includes:
o Fillings (e.g. young children
admitted to a day clinic)
o Extractions (e.g. young children
admitted to a day clinic)
Surgical extractions (e.g.
impacted wisdom teeth)
o Root Canal Treatment
o Non-elective surgery (e.g.
periodontitis)
“Balance Billing” ¹ - separate provider
fees that are non- refundable by the
member’s medical scheme. This
occurs where the provider charges the
scheme tariff for the billable items on a
procedure and then adds a separate
fee over and above the tariff items.
Usually schemes ignore this additional
fee and it does not appear on their
claims remittance, or, if it does
appear, then it shows as a zero paid
item.
Claims older than 6 months.
o
¹ if balance billing is undertaken where the
additional fee (over and above the tariff
items charged) is shown on a separate
statement, this practice is called “split billing”
and is considered to be illegal.
7. Application Procedure
Application forms
1. Xelus requires each applicant to
complete an individual application
form (online or PDF e-Form)
2. On
completion
of
our
online
application both the member and
broker will receive a confirmation email
along with the relevant disclosure
document.
3. Once Xelus receives these application
forms, members will be loaded on the
system.
4. On acceptance, policy documents will
be sent via email to each member.
5. Should application be declined, notice
thereof will be sent to the member via
email.
We can load a 2nd email address on our
system so that intermediaries are copied when
these policy documents are issued.
8. Claim Procedure
Members can request a claim form from our consultants, or by clicking here.
There is an option for members to sign an authority for Xelus to obtain the relevant claims
information on their behalf. For Discovery and Momentum – members must sign the relevant
authority form from their medical scheme (these are available from our office or click on the
relative web link at the base of our claim form).
In doing so, we will be able to obtain the outstanding supporting documentation on their behalf.
If members do not sign the authority form, the following supporting documents are required:
1. Claims Transaction History Report
2. Relevant Doctors Accounts
3. Hospital Account (first one – four pages showing admission & discharge times and ICD
codes
4. Current medical scheme membership certificate (copy of the membership card is not
accepted)
9. Claim Procedure continued
The biggest delay in processing claims results from our outstanding documentation. If you are
assisting a client with a claim please emphasise that all material above is require otherwise claims
will not be processed.
Claims are processed continuously as and when received by Xelus and payments are made on a
daily basis.
An email and sms notification is issued to the member when:
The claim is captured,
Requesting outstanding documentation (assuming they have not signed the authority
form)
Authorising the claim
Important Notes
EFT payments can only be made to the principal member – by law we may not pay service
providers.
10. Contact Details
Office Number
0861 11 11 67
Administrative Queries
General Admin, Escalated Queries and
Commission
Megan Steyn │E-mail: [email protected]
Operations
(Clients are allocated to one administrator who
undertakes all related tasks for that clients – billing,
claims and applications)
Arno Strauss │E-mail: [email protected]
Corlea Kruger │E-mail: [email protected]
Laura Hill │072-455-7162│mail: [email protected]
Verner Strauss │E-mail: [email protected]
Mia Louw │E-mail: [email protected]
Michelle van Rooyen │E-mail: [email protected]
Marketing / Presentations / Training