Agility Gap Cover


Frequently asked questions:


What is gap cover?


Your daughter needs to have a gastroscopy to investigate upper abdominal pain and the procedure requires the services of an anaesthetist. The anaesthetist charges 200% of the medical scheme rate while your specific option will only cover 100%. Expect to receive a surprise bill in the post following the procedure, stating that you must cover the tariff shortfall from your own pocket.


This portion of your medical bill, often being a large amount that you need to pay, is referred to as the gap between what your medical scheme has paid out and the actual cost of treatment you receive in-hospital.


Most medical schemes pay claims out at a specified rate (also known as a scheme rate) and you will notice a sizeable gap between the amount charged by doctors for services rendered in-hospital and the amount actually paid by your medical scheme.  The following is an example of this scenario:


When does this cover apply? 


This policy covers you for procedures that are performed in-hospital. However, you will also be covered for specified out-patient procedures that are done in the doctor’s rooms instead of in hospital care. The list of out-patient procedures include:


  • General surgery

  • Urology

  • Opthalmology

  • ENT surgery

  • Orthopaedic

  • Paediatric surgery

  • Hepatobiliary surgery

  • Cardiothoracic surgery

  • General medical cardiology

  • Neurology

  • Immunology

  • Gastroenterology

  • Radiology



What cover options are available?


The Agility Gap cover suite includes 3 products that are perfectly suited to the varying healthcare needs, and pockets, of its client base:


  • Agility Gap 200 @ R63,55 per family per month: Pays medical professionals for in-hospital and specified in-room procedures at up to 200% over and above the medical scheme rate of your option


  • Agility Gap 500 @R153,33 per family per month: Pays medical professionals for in-hospital and specified in-room procedures at up to 500% over and above the medical scheme rate of your option


Does the policy cover day-to-day services? 


No. Agility Gap covers mainly in-hospital shortfalls as well as certain listed procedures that might be performed on an out-patient basis.  Day-to-day services such as doctor’s visits, specialist visits, spectacles, etc. are not covered.



Who needs gap cover?


All individuals covered by a medical scheme in South Africa are able to obtain gap cover. The gap policy will cover professional rates provided in-hospital.



Do I need to be a member of a medical scheme to qualify for gap cover? 


Yes, you can only enjoy cover under this policy for as long as you’re a member of a registered medical scheme. This policy works together with your current medical scheme.



Do I need to submit the original accounts when I claim?


No, faxed or emailed copies are accepted when submitting a claim.



How do I apply?


Simply download the application form from our website here or apply online.  Our experienced team will guide you through the process and advise you should you require any assistance.



How do I claim?


  • Step 1: Submit a completed claim form (click here to download). 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. This would include 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:


Is the premium stipulated for the whole family?


Yes it is. This policy is specifically designed for a maximum of 3 adults with 2 children OR 2 adults with 3 children.


What exclusions does gap cover have?  


Some important exclusions you should be aware of are:


  • The 1st 100% of the cost is not covered as this is usually covered by the medical scheme

  • Costs incurred for the treatment of Prescribed Minimum Benefits (PMBs) as this must be paid by your medical scheme in terms of the Medical Schemes Act 131 of 1998

  • The following conditions within the first 12 months of the policy inception:

    • Myringotomy and grommets

    • Adenoidectomy

    • Tonsillectomy

    • Pregnancy / confinement, or any related complications

    • Hysterectomies (except where malignancy can be proven)

    • Joint replacements (except in the case of an accident)

    • Spinal, neck and back procedures

    • Hospital account shortfalls

    • Any medical scheme exclusions

    • Psychiatric and psychological disorders

    • Any hazardous sport

  • Claims that occur within the first 3 months after inception of cover, except in the event of an accident.  

Is pregnancy covered?


Child birth is covered but has a 12 month waiting period from the date of signing your policy. Should you already be pregnant, the baby will be covered after the birth, keeping in mind that this could also be subject to underwriting depending on the condition of the baby. 


What about my pre-existing conditions?


If you have a pre-existing condition, the underwriters will assess the risk and more than likely put a 12 to 24 month exclusion on the policy just like any medical scheme would. Remember that special underwriting concessions exist for groups and to contact us for more info on 021 918 6210.



What is the maximum entry age?


There is no maximum entry age. 


Which Insurer underwrites this policy?


GENRIC Insurance Company Limited.



Who gets paid when my claim is settled - the doctors or me?


All claims will be paid to the principal member. This is in line with the Short Term Act which states that we may not, under any circumstances, directly settle the claim with service providers.



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.