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An example: 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 graph illustrates an example of this scenario:

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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

• Ophthalmology

• ENT Surgery

• Orthopaedic

• Paediatric surgery

• Hepatobiliary surgery

• Cardiothoracic surgery

• General medical cardiology

• Neurology

• Immunology

• Gastroenterology

• Radiology.

• Obstetrics and Gynaecology

• Hyperbaric oxygen treatment

• The necessity for chemotherapy or radiotherapy for the treatment of cancer on an out-patient basis (excluding Biological drugs)

• The necessity for kidney dialysis on an out-patient basis

Click HERE to view the full range of Gap & CoPay products.

Agility Gap cover provides 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.

However, specified day-to-day, or out-of-hospital benefits are available on the Agility Combined & Agility Corporate product ranges.

Click HERE for more information.

All members of a registered South African medical scheme are able to obtain gap cover. The gap policy will cover professional rates provided in-hospital.

Co-payment cover is available on the Agility Combined range in addition to gap cover. Co-payment benefits provide cover for hospital admission co-payments (or deductibles) as required by your medical scheme for certain procedures before being admitted to hospital. It also provides cover for co-payments, or shortfalls on specialised radiology such as MRI or CT scans. Click HERE for more information about the Agility Combined & Agility Corporate ranges.

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.

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

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.

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: gapco@agilityinsurance.co.za

Yes, you can. A maximum of 3 adults (principal, spouse, and dependant parent) and 2 children, or 2 adults and 3 children will be insured under one policy. A maximum of 5 persons can be Insured by this policy. Dependents are defined as partners, spouses, biological parents, biological children, or children legally adopted.

This policy will cover a child dependent up to the age of 21, however cover can be extended to the age of 27 for full time students (documented proof is required).

Some important exclusions you should be aware of are:

• Any claims or claim portions not authorised or paid by the principal members’ Medical Scheme

• The first 100% of the Medical Scheme Rate (This will normally be covered by your medical scheme)

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

  • Myringotomy & 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

  • Medical scheme exclusions and admission fees

  • Out-patient treatment other than defined as covered

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

Childbirth 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.

If you have a pre-existing condition, the underwriters will assess the risk and more than likely put a 12-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.

A maximum entry age of 59 applies.

GENRIC Insurance Company Limited.

All claims will be paid to the principal insured. 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.

There is a regulated limit of R201,000 relevant to each insured beneficiary. This limit applies to all gap & co-payment claims during a benefit year. In addition, some benefits may attract stated sub-limits. Please refer to the benefit overview HERE for more information.