Agility Combined Cover
Frequently asked questions:
What does the Agility Combined product include?
The Agility Combined cover product includes the following 3 components:
Gap cover: Gap cover provides financial protection against the difference between your Medical Scheme Rate and private rates charged by a Registered Medical Professional for in-hospital treatment. Gap cover will settle up to a maximum of 500% of your Medical Scheme Rate in these instances.
Co-pay cover: This product will cover your co-payments for procedures performed in-hospital as well as some specified out-patient procedures. This includes MRI, CT and ultrasound scans. An incident limit of R12 000 applies per claim which means that your co-payment will be covered up to a maximum amount of R12 000 per insured per incident. Utilisation per beneficiary is limited to no more than 3 claims per annum with an overall annual limit of R120 000 per family.
Out-patient cover: This product covers the difference between your Medical Scheme Rate and private rates charged by a registered medical professional. The policy will cover you for out-patient surgical procedures that would normally be performed as an in-patient. An incident limit of R3 000 applies per claim which means that your specified out-patient treatment will be covered up to a maximum amount of R3 000 per insured per incident. Utilisation per beneficiary is limited to no more than 3 claims per year with an overall annual limit of R15 000 per family.
The list of out-patient procedures includes:
General medical cardiology
Why would I need this product?
The Agility Combined product is near essential to anyone who belongs to a medical scheme. All major in-hospital admission shortfalls, like registered medical professional fees, co-payments and admission fees, are covered.
What are my cover options?
The Agility Combined basket includes 4 products, each of which is perfectly suited to the varying healthcare needs, and pockets, of our diverse client base:
Agility Combined 200: For R129,12 per family per month, this basket will cover in-hospital and in-room procedures up to 200% over and above your medical scheme rate as well as provide protection against in-hospital procedural co-payments.
Agility Combined 350: For R183,60 per family per month, this basket will cover in-hospital and in-room procedures up to 350% over and above your medical scheme rate as well as provide protection against in-hospital procedural co-payments.
Agility Combined 500: For R260,26 per family per month, this basket will cover in-hospital and in-room procedures up to 500% over and above your medical scheme rate but include added benefits such as:
- An unlimited number of claims for in-hospital procedural co-payments.
- R25 000 cover if you want to use a surgeon of your choice instead of your medical scheme’s network provider for Prescribed Minimum Benefit (PMB) conditions
- A useful Emergency Room Benefit of R6 000 per annum
Agility Ultra: For only R383,33 per family per month this exceptional product can boost your Agility Combined 500 cover with additional benefits for those instances where:
- Your medical scheme benefits are depleted
- You need additional in-hospital cover
- You need added cover (R35 000 per annum) to use a surgeon of your choice instead of your medical scheme’s network provider for Prescribed Minimum Benefit (PMB) conditions
- You need to cover any penalty co-payments
- You want to include dental and ophthalmology cover
- You need out of hospital cover for specialist consultations
- You need an unlimited number of claims for procedural co-payments
Are there any waiting periods?
There is a 3 month general waiting period and a minimum of 12 months on pre-existing conditions.
How do I claim?
Step 1: Submit a completed claim form. Ensure that all sections are completed in full and that you have signed the claim form.
Step 2: All provider accounts relating to the procedure must be attached and submitted at the same time, including the hospital, surgeon and anaesthetist accounts.
Step 3: Attach a copy of the medical scheme statement indicating scheme payment towards the claim.
Step 4: Submit your claim to: firstname.lastname@example.org
What about dentistry and optometry care?
The Agility Value Added Product (VAP) provides extensive in-hospital cover for dental and optometry gap claim shortfalls at an affordable rate of R25 per family per month. Should you not take the VAP additional cover, these in-hospital dental and optometry gap claim shortfalls will be excluded.