Agility Combined Cover

Frequently asked questions:

01

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 surgery

• Urology

• Opthalmology

• ENT surgery

• Orthopaedic

• Paediatric surgery

• Hepatobiliary surgery

• Cardiothoracic surgery

• General medical cardiology

• Neurology

• Immunology

• Gastroenterology

• Radiology

02

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.

03

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

04

Are there any waiting periods?

There is a 3 month general waiting period and a minimum of 12 months on pre-existing conditions.

05

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: gapco@agilityinsurance.co.za

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06

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.