Frequently asked questions
In South Africa, the key difference between medical aid and medical insurance comes down to how they are regulated and the extent of the benefits they provide. Medical aid schemes are run as non-profit entities and regulated by the Council for Medical Schemes (CMS). They are required to cover an extensive “whole basket” of healthcare benefits, including hospital care, day-to-day medical needs, chronic conditions, and a wide range of prescribed minimum benefits. This means medical aids offer comprehensive, full-spectrum medical cover across all age groups, without the ability to decline members based on risk.
Medical insurance, by contrast, is an insurance product regulated by the Financial Sector Conduct Authority (FSCA). Our medical insurance offers many of the same essential healthcare services—including day-to-day care, dental benefits, hospitalization, and accidental hospitalization—but within clearly defined limits. For example, we set fixed maximum payouts for certain procedures and we do not onboard members over the age of 65. These limitations help us control risk more tightly and manage costs more predictably. As a result, we can offer significantly lower monthly premiums compared to traditional medical aid, while still providing a broad and practical range of benefits suited to everyday healthcare needs.
You can go to any Radiologist, totally your choice. You’ll just need to pay upfront, and then you have 90 days to claim it back with us._Just send us the invoice, proof of payment, and your policy number._Once everything is submitted, we’ll reimburse you within 14 business days — up to your available benefit limit
You need to use a dentist on the AGS Dental Network. If you go outside the network, the claim won’t be covered.
Just show your digital card and the network dentist will claim back from us directly.
You can find the list of network dentists either through the AGS Health Mobi-App or through our online portal.
You can use any general practitioner you like, but AGS Health does have a list of preferred GPs. If you go to a preferred provider, they’ll handle the claims directly with AGS Health, which is convenient. You can check the current list of these preferred GPs on our website or through our mobile app. Just keep in mind that the list can change, so it’s a good idea to confirm with your GP if they’re still a preferred provider. But if you want to see a non-preferred GP, that’s totally fine—you’ll just pay upfront and then claim back afterward. Re-imbursement takes up to 14 days if paperwork is in order.
You can use any pathologist you prefer because AGS Health doesn’t have a specific pathology network. That means you’ve got the flexibility to choose whichever pathologist works best for you. You’ll just pay upfront and then submit your claim to AGS Health afterward for reimbursement. Just remember to include all the necessary details like your policy number and proof of payment when you claim. But in short, you can pick any pathologist you like!
If you don’t get pre-authorization before a hospital admission or a planned procedure, then there’s a risk that the claim might not be covered by AGS Health. Essentially, the pre-authorization is there to make sure that the treatment is approved under your benefits. Without it, you could end up having to pay out of pocket or deal with a declined claim. So it’s definitely a good idea to always get that pre-authorization to avoid any issues. If something is truly an emergency and you couldn’t get authorization beforehand, you should contact AGS Health as soon as possible afterward to let them know. But in general, skipping pre-authorization can lead to the claim not being paid by AGS Health.
A medical condition that develops slowly over time, not suddenly, and not because of a specific accident or event.
In simple terms, it is any illness, damage, or condition that worsens or appears progressively, rather than being triggered by one clear incident. Very much like “wear and tear”.
No cover for hospital admission for investigative procedures only. If the admission is ONLY for investigation (e.g., MRI, CT, scopes) it is not covered unless the agreement says otherwise.
Pregnancy complications are excluded for the first 12 months
Suicide, self-harm, intentional danger
Self-inflicted injuries or risky intentional behaviour excluded.
Routine examinations without medical necessity
General check-ups not linked to illness/injury excluded in hospital.
Obesity treatment, elective cosmetic surgery, eye surgery Unless reconstructive due to an accident.
Protects against pre-existing pregnancies.
Newborns not covered for first 12 months unless discharged healthy
Failure to follow medical advice or treatment. No cover when neglecting medical care.
Hospital stays without medical necessity. No coverage for voluntary/unnecessary admissions.
Admission for investigation of pain or pain-related conditions. Pain-only investigations like spinal blocks, physiotherapy, traction, meds, IV meds excluded.
Failure to prevent accidents / non-compliance with law. Reckless or unlawful actions void claims.
Alcohol or drug-related incidents. Unless prescribed medication.
Nuclear, biological, chemical, explosive weapons or contamination
Underage or unlicensed drivers. Accidents not covered if driver is illegal/unlicensed.
Air travel other than as a passenger. Crew, pilots, or technical flight roles excluded.
Hazardous or professional sports. High-risk activities excluded.
Psychiatric hospitals.
Extreme sports & activities. Mountaineering, skydiving, racing, diving >30m without certification, etc.
Illegal acts. Injuries during unlawful acts excluded.
Gradually evolving conditions. Degenerative or chronic slow-progressing issues excluded.
STD treatment except if linked to a reported crime. Example: sexual assault cases covered.
Services by unregistered providers. Must be registered with HPCSA / Medical & Dental Council.
Sterilization, birth control procedures, infertility treatment. Mirena insertion/removal included as exclusion.
Abortions. All terminations of pregnancy are excluded.
Cannot claim for the same event under multiple benefits. No double dipping on the same incident.
ALL eye operations excluded unless due to an accident.
Maternity benefit only covers births in a Hospital. Birth clinics, midwives, home births excluded.
Follow-up or corrective surgery linked to past surgery (within 5 years) excluded. Anything tied to a surgery in the 5 years before policy start is excluded.
All circumcisions excluded. Routine or medical — all excluded.
Medication not approved by the medicines board / alternative healers excluded. Homeopath, traditional healer remedies excluded.
Illness & hospitalisation exclusions for specific diseases. These are excluded:
Kaposi’s Sarcoma
Pneumocystis carinii
Tuberculosis
CMV
Cryptococcal meningitis
Cryptosporidium
Disseminated Herpes/Shingles
HIV/AIDS
Disclaimer
These exclusions are based on the policy wording, but additional exclusions or limitations may apply. The official policy document always takes precedence.
You can choose to cover just yourself or include your spouse and children as dependants. Each member listed on the policy will have access to the same benefits according to the plan rules. Premiums will adjust based on how many people you add. It’s important to confirm ages because certain benefits and waiting periods may apply differently. This also helps us recommend the most affordable option for your family size. Maximum members on a plan are 6 however, with no more than 4 children.
Yes, emergency visits are covered, but note that pre-authorisation is extremely important. This protects you when urgent help is needed—such as heart attacks, strokes, or severe injuries. Non-emergency visits may not be covered, so the nature of the event is important. There are also limits per event. We help guide you so you know exactly when you’re covered.
Yes, ambulance transport is covered for life-threatening emergencies and must be authorised before dispatch. This ensures you receive fast response and safe transport to a medical facility. Knowing when to call us is key. We always guide you through the process.
These procedures are only covered if they relate to an accident. Investigative scans for illness or pain are not covered. If a scan is needed because of an accident, it will be handled under the accident benefit.
Certain procedures like joint replacements, back surgeries, cosmetic operations, eye surgeries, and blood transfusions are not covered, unless they are directly caused by an accident. This keeps the plan focused on sudden, unexpected medical needs, rather than long-term or elective care. We explain each exclusion clearly so there are no surprises. The goal is transparency and good expectation-setting.
Yes, but only after a waiting period and only in a hospital, not at birth clinics or with midwives. There are also limits on maternity benefits that we explain upfront. Pregnancy complications in the first year are excluded. We ensure expecting parents understand timing requirements clearly. This helps with planning and avoids unexpected costs.
No, the plan does not cover any abortion procedures. This includes elective and medically recommended terminations. It’s an important factor for clients to be aware of upfront. We ensure clarity so you can make informed choices. This exclusion is standard across many medical insurance products.
Eye surgeries are not covered at all, unless they are directly caused by an accident. This includes cataract surgery, laser corrections, eyelid procedures and anything similar. The accident-only rule ensures emergency situations are supported. Routine or illness-related eye procedures remain excluded. We make this clear for clients with pre-existing eye conditions.
There is a fixed limit per event and an annual maximum for each insured member. This protects you during serious hospital events while keeping cover affordable. If multiple events occur, each is handled individually until limits are reached. Families also have a total annual cap. We explain these limits using simple examples during onboarding.
Hospitals sometimes require upfront deposits, especially for planned procedures. The insurer pays deposits only for maternity cases under strict rules. For other admissions, the pre-authorisation ensures the hospital knows you have cover. We help guide you through each step before admission. This prevents unexpected cash requests at the hospital. Should the hospital require a upfront / pre-payment in regard to emergency situations, we handle those on the members behalf.
Chronic conditions are recognised, but coverage depends on the illness-and-operations benefit limits. Some chronic-related complications may be excluded based on policy rules. We assess your condition to see whether this plan suits your needs. If a chronic condition requires ongoing hospital care, we explain what is and isn’t covered. Our goal is to ensure you choose the right product for your health profile.
These specific conditions are excluded from the illness and hospitalisation benefit. This is important for clients who have or may be at risk for these illnesses. We discuss this honestly during onboarding to prevent misunderstanding. Despite this exclusion, other accident-related issues remain covered. We help you understand where the plan fits and where it doesn’t.
Newborns are not covered for the first 12 months unless they are discharged healthy and meet policy conditions. This means premature or medically complex babies may have limited cover initially. We guide parents on how and when to register newborns. Understanding this helps parents plan ahead and avoid unexpected medical costs.
Pre-existing conditions are excluded for the first 12 months. Dread diseases however have a 24 month waiting period. After 24 consecutive months on the plan, these conditions are no longer excluded. We review your medical history to identify any waiting periods. Transparency here prevents disappointment later.
If the surgery relates to a procedure done within the previous five years (before joining), it is excluded. This ensures the plan doesn’t take on historical medical costs. New or unrelated surgeries are covered within benefit limits. We help assess your history to avoid future claim issues. It’s part of choosing the right plan.
Your plan pays shortfalls only, not the full amount, if COIDA or RAF applies. This prevents duplication of benefits. You still get protection for out-of-pocket costs. We help coordinate all channels so you get maximum support. This ensures accident claims are handled smoothly.
If six months have passed since the previous illness and it has a clear new diagnosis and treatment plan. This prevents repeated claims for the same condition too close together. It also helps the insurer manage risk while still offering fair cover. We explain this clearly with examples. This ensures expectations are realistic.
Hazardous and professional sports are not covered under the accident benefit. This includes high-risk activities like skydiving, off-road biking, mountaineering and more. Normal recreational activities are fine. We tell you upfront if a hobby affects your cover. This helps avoid surprises during claims.
You must notify AGS Health at least 48 hours before any planned hospital admission. If it’s an emergency, call as soon as you practically can — within 48 hours after admission — otherwise the claim may be declined. Pre-authorisation is required for many benefits; failure to obtain it can lead to non-payment.
You need to submit all required documentation within 3 calendar months of the claim event. For non-network providers (e.g., non-PPN optics or non preferred GP’s), you usually pay upfront and must claim back within 90 days with proof of payment. AGS aims to reimburse valid claims promptly — for non-preferred provider pharmacy claims the turnaround is stated as within 14 working days after submission. Keep originals and full statements; incomplete paperwork delays payment.
Dental:
You must use a dentist within the AGS Dental Network (managed by Dental Risk Company).
Claims from non-network dentists will not be covered.
We always recommend checking the provider lookup tool before your visit to confirm the dentist is on the network.
Pharmacy:
AGS uses Mediscor as the preferred pharmacy network.
Preferred pharmacies submit claims directly to us.
If you use a non-preferred pharmacy, you’ll need to pay upfront and then claim back within 90 days.
Just send us the invoice, proof of payment, and your policy number.
Once we have everything, we’ll reimburse you within 14 business days, up to the available benefit limit on your plan.
GPs:
You’re free to visit any GP — on or off the network.
If you use a GP on the AGS GP Network, simply show your digital card and the GP will claim directly from us.
If you use a non-network GP, you’ll need to pay upfront and then claim back within 90 days.
Just send us the invoice, proof of payment, and your policy number.
Once we have everything, we’ll reimburse you within 14 business days, up to the available benefit limit on your plan.
We always recommend checking the provider lookup tool before your visit to confirm the GP is on the network.
Implants and crowns require pre-authorisation and are limited by the schedule of benefits; an implant is once per lifetime per tooth and placing an implant resolves that tooth’s event for five years. A crown or implant placed on a tooth means no further cover for that tooth for 5 years; after five years additional cover is limited (e.g., crown replacement from crown benefit only). If an implant fails, re-treatment isn’t covered as a repeat implant — denture cover may be available instead if your option includes dentures.
Wisdom tooth procedures also require pre-authorisation for specialised dentistry. There are limits per year and per plan — extractions in chair vs in hospital are treated differently and you can’t claim both in the same year. Each third molar extraction is covered once per lifetime per molar, and the maximum monetary amounts are in the schedule of benefits. Dentists must motivate hospital extractions if requested.
Trauma benefits apply for events that are clearly traumatic/accidental, and you must submit an accident report from SAPS or an ER confirming the incident. There is a 1-month waiting period for trauma cover and monetary limits are defined in the schedule (examples show ~R30,212 for some options). Trauma is only payable if the trauma date is after the policy inception and you are an active member at the time. Keep police/ER documentation tight to avoid disputes.
Ambulance (road) cover is available for life-threatening emergencies and must be pre-authorised before dispatch. The policy lists a per-event limit (example: R35,000 per event Africa Assist. There is a 12-month waiting period if the life-threatening event relates to a pre-existing condition. Always call the AGS helpline to authorise ambulance dispatch to ensure cover.
No — orthodontic treatment is fully excluded under this policy and cosmetic dental procedures are not covered under any circumstance. The plan focuses on clinically necessary dental care (fillings, extractions, emergency root canals, crowns where indicated) rather than elective cosmetic work. If you need orthodontics or cosmetic dentistry, you’ll need to budget separately or seek a different product.
You have a 31-day cooling-off period from receipt of your policy documents to cancel. The policy lapses after two missed premiums (not necessarily consecutive) and benefits are not available during lapse. To cancel you must give 31 days’ written notice; similarly AGS gives 31 days’ notice for changes. Reinstatement of a lapsed policy may be considered within 30 days but is at the insurer’s discretion.
Benefits are payable only within the borders of the Republic of South Africa. Entry and cessation ages are specified: Principal insured entry age typically 18–65 (some options up to 80 for certain standalone options) and cessation ages apply (e.g., cover may stop or move categories at older ages). These limits affect eligibility and premium categories, so confirm ages at application.
Your plan does include optical benefits, and you can get glasses as long as your prescription meets the minimum strength required by the policy. To enjoy the smoothest experience, it’s best to visit one of our network optometrists — Specsavers or Execuspecs — because they claim directly from us, so you don’t pay upfront. If you prefer to use your own optometrist, that’s also fine, but you’ll need to pay first and claim back within 90 days. Low prescriptions that don’t meet the minimum dioptre rules unfortunately aren’t covered. We also offer additional support for bifocals or multifocals if you qualify based on age and plan type. Overall, you have freedom of choice, with the best value through our preferred network.
AGS Health (PTY) LTD is an authorized Financial Services Provider (FSP 48780), underwritten by Africa Unity Life Limited, a licensed insurer and an authorized FSP:8447. The AGS Health Benefit Plan is demarcated by CMS. This product is a Medical Insurance Product and not a Medical Aid registered by the Council for Medical Schemes DM1053D. For more information regarding this demarcated product please visit https://www.medicalschemes.co.za/insurers/ © 2025
