For many of us who have been in the medical industry for some time, we might remember the term locomotor system – which has been replaced by the more modern term ‘muscular-skeletal’. The industry-standard definition of the muscular-skeletal system is “the skeleton and connective tissues (muscles, ligaments, joints and tendons) which are directly involved in support, protection of vital organs and movement of the body.” It’s important to emphasize that muscular-skeletal conditions do not merely refer to a break or fracture in a bone, but also to the surrounding impact on the connective tissues – such as muscle tears, internal inflammation (osteoarthritis) and muscle sprains. Turnberry defines muscular-skeletal as any diagnosis or condition relating to bones, muscles, cartilage, tendons, ligaments, joints and/or connective tissue.
From this definition, we can classify muscular-skeletal issues as being either traumatic or chronic conditions.
A traumatic condition would be caused by some form of trauma to the body for example a broken bone or a torn ligament. Most traumatic muscular-skeletal conditions would be a Prescribed Minimum Benefit (PMB). PMBs are a list of 271 medical conditions and 25 chronic conditions legislated by the Medical Schemes Act 131 of 1998, that medical schemes need to fund in full from the risk benefit, provided that a member makes use of the medical scheme’s Designated Service Providers (DSP). Should a member voluntarily choose not to make use of a DSP then they could be liable for a medical expense shortfall.
Chronic’ muscular-skeletal conditions often develop based on predispositions or due to ageing for example arthritis or the need for a joint replacement due to wear and tear.
So, just what does this mean for your clients in terms of Gap Cover?
Some of the most likely types of muscular-skeletal claims include hip bone fractures/ replacements, lower back pain, shoulder inflammation (e.g. rotator cuff tendonitis), ligament tears or sprains and herniated spinal discs. Many of these conditions could require surgical intervention where you may need to pay an upfront co-payment to the hospital prior to undergoing surgery or one may even need to pay an upfront co-payment to the radiology department for a MRI or CT scan.
Surgery could result in medical expense shortfalls if the surgeon and/or the anaesthetist charges in excess of medical aid rates. In addition to this for more complicated surgeries such as a joint replacement, an internal prosthesis may be required and should the cost of the prosthesis be in excess of the benefit offered by one’s medical scheme then the Sub-limit Cover Benefit offered by Gap Cover Benefit could assist with this medical expense shortfall.
For minor traumatic muscular-skeletal injuries a trip to Casualty might be the order of the day. Most medical schemes cover a trip to Casualty from one’s day-to-day benefits if you are not admitted straight from Casualty. Should your day-to-day benefits be depleted then this would be a cost for your own pocket, it you do not have a Gap Cover product that offers a Casualty Benefit for Accidents.
Waiting Periods
It is important to note that a member joining Gap Cover will have a 12-month waiting period for muscular-skeletal conditions, from the date of commencement of the Policy. But do not despair the 12-month waiting period for muscular-skeletal conditions will not apply to accidents that occurred while on a Policy.
Claims paid by Turnberry over the past 12 months
Coxarthrosis
Provider: Anaesthetist
Amount Charged: R13 880.22
Medical Aid Paid: R4 679.73
Amount paid by Turnberry:
R8 374.16
Provider: Orthopaedic Surgeon
Amount charged: R40 822.68
Amount paid by Medical Aid: R12 889.20
Amount paid by Turnberry:
R27 932.68
Hospital Co-Payments paid by Turnberry:
R4 930
Total amount paid by Turnberry:
R41 236.84
Other Idiopathic Scoliosis, Thoracolumbar Region
Provider: Anaesthetist
Amount charged: R46 325.88
Amount paid by Medical Aid: R15 064.58
Amount paid by Turnberry:
R38 000
Sub-Limit for prosthesis paid by Turnberry:
R35 000
Provider: Orthopaedic Surgeon
Amount charged: R96 269.52
Amount paid by Medical Aid: R42 786.62
Amount paid by Turnberry:
R40 356.91
Total amount paid by Turnberry:
R171 000
Client Testimonials post claim submissions
I have been a Turnberry customer for the past 15 years and in this time, I have made several claims. Most recently, I had a hip replacement operation in November 2021. I was in hospital for around a week, but before I was even admitted, I had to pay an upfront co-payment of R4 930. In addition to this, both the surgeon and the anaesthesiologist charged three times the medical aid rate for my surgery, which amounted to shortfalls of R27 932.68 for the orthopaedic surgeon and R8 374.16 for the anaesthesiologist. Without my Turnberry gap cover policy, this surgery would have left me with R41 236.84 in shortfalls, which I would have had to cover out of my own pocket. Not many people have this amount of money lying around to cover such unforeseen expenses. I would have had to negotiate with the doctors to reduce the amount I needed to pay and pay it off over time or take out a loan. This would have been a tremendous additional stress at a time when I needed to be focused on recovering from my operation. Thanks to my gap cover, however, I knew that this would be covered, which gave me peace of mind right from the start. For me, gap cover has been invaluable. Over the years, Turnberry has paid out more than R100 000 on my policy, all of which would have come out of my pocket if I had not had the policy. The premium itself is a relatively small price to pay, and I believe that gap cover is essential for people of all ages, because you just don’t know when accidents or illness will strike. Turnberry’s service is truly excellent, the courtesy extended to me by all the staff is wonderful, and when queries arose, they were handled swiftly. From the call centre to claims assessors, the service has always been prompt and efficient and the turnaround times are fantastic. Len Leuw
Deeply grateful for the recommendation. Especially so when we discovered that the key professional for the procedure was not on the Medical Aids ‘list of service providers’ and so would not grant authorization!!!! We had to go ahead anyway. I would recommend Turnberry without hesitation. Advice – don’t think about it, take it! Anon
Turnberry saved me so much money that I would have had to pay out of my savings, after my knee operation. In to-day’s society, it is imperative to have this cover because every medical aid has a shortfall of payments. Support of the Turnberry team is excellent and I highly recommend their services. Tanita Coetsee
I was able to claim the added expenses after my knee surgery. I have had no problems with Turnberry and their service was helpful and efficient. Gap Cover Insurance is something that unfortunately in today’s times needs to be considered. A small expense to give one peace of mind. Turnberry claims division were quick and helpful in answering my questions. Dave
Recently had an operation to repair the cartilages in both knees. Although Medical Aid covered most of the in-hospital costs, there were a couple of areas, namely the Surgeon, the Anaesthetist and MRI scan costs that the Medical Aid didn’t cover. This was due to the Drs charging above medical aid rates and the medical aid only covers a portion of the MRI scan. Turnberry Gap Cover covered these shortfalls which amounted to 55% of the Surgeon and Anaesthetist costs and 45% of the MRI scan. The small amount of money you pay each month for gap cover far outweighs the bills you may eventually receive in the event that you need to be hospitalised for elective or non-elective surgery – you are at the mercy of the doctors once you are hospitalised. Highly recommend that you have gap cover. Turnberry offers First class service – the speed at which the claims were settled was fabulous. There was a query on one of the Drs accounts – Turnberry notified me of the query and stated that they would be handling this. I was required to submit the invoices of the doctors and what had been submitted to the medical aid – Turnberry handled the rest, including paying one of the doctors directly. Jennifer Hudson
It gives me great pleasure to congratulate Turnberry on their outstanding and most professional service I received, having just recently had a knee and neck operation. Obviously the paperwork was submitted timeously by the suppliers, which I was able to forward straight to Turnberry offices. The payment into my bank account was really speedy and they kept me updated with all relevant details per email. In this day and age when service from companies can only be described as inefficient and abominable to say the least, what a pleasure to have a professional company like yourselves, willing to help and sort out the payments. Customers at this stage are dealing with numerous bills and in a state of recovering from the operations, so efficient service just alleviates some of the pressure. A very big thank you. Debbie Westwood
I had gap cover for years but never used it. Still the shortfall that I had with my knee replacement was 2/3 of the amount charged by the orthopaedic surgeon and the anaesthetist. If I had to pay that I would have been in debt of a very long time, because it was a lot of money. Even if it wasn’t for Covid, my salary cannot afford the gap for such a huge operation. I do not know how can people survive without gap cover! People young and old must really have gap cover. This is not for old people but anything can happen to you and your medical aid is by far not enough to cover important operations. Adele van der Walt
I have been with Turnberry since 2010. When my wife and I joined, we were only 28 years old and healthy. Life happened and 3 years ago I was diagnosed with a muscle disease. It took numerous tests and biopsies to determine the extent of the disease, as well as hospitalizations and surgery, which costs more than I could ever afford. I got into contact with Turnberry and after explaining my condition to them, they placed themselves in my shoes and gave me sound advice as to what they can do for me. I changed to the Optimal Plan, as the plan I was on when I initially joined was for a healthy 28-year-old. In the last 2 years, I have been hospitalized 3 times and I have been seeing 2 Neurologists. We know these things costs money and most medical aid plans (the ones I can afford) does not cover all of the above or just a percentage. I have received doctor and hospital bills after the medical aid contributions that caused my heart to skip a few beats. Turnberry’s Gap Cover saved me every time. The process of getting these bills paid is quick and easy, it’s as easy as sending a mail or WhatsApp, literally that’s all it takes. I am pleased to say that Turnberry has had my back and will continue to do so with whatever life throws at me. Thank you to the Turnberry team. Dewald Human
If it wasn’t for gap cover I would have had enormous medical expenses. I have had to claim twice in one year. Don’t think about it just do it! It’s the right thing to do. One never knows when you might need the gap cover. I broke my foot just before lockdown due to a brick that was left on a pavement after someone had a motor vehicle accident and they kept the robot upright with the bricks. Whomever did that left some of the bricks on the pavement and at 5h00 in the morning I didn’t see the bricks… Needless to say I ran into the brick and that’s how I broke my foot. Unexpected medical disbursements which I did not budget for and already had to undergo two operations. I have had many expenses and I can truly recommend gap cover. I would recommend Turnberry Gap Cover and have already done so amongst my colleagues at the office. I rate their services as – Excellent! Louna van Tonder
Turnberry’s Gap Cover Insurance benefited me in a major way as after my back surgery there were some horrifying bills from specialists that my medical aid did not cover as rates were up to 400% higher than medical aid rates. Turnberry without any questions jumped in and covered all these bills, did not cost me a cent and I am very appreciative to Turnberry for coming through for me. Without a doubt. I would recommend Turnberry to anybody looking for a GAP cover. Would I recommend Turnberry Gap Cover Insurance – All I can say is, why have you not yet taken it out, does not cost much at all and the benefits are massive when you need to be covered which could come at any time. I would rate their services as ‘Excellent’ is the first word that comes to my mind. The service that I received from Turnberry was far beyond what I ever expected, professional, quick and just so easy. Everything explained as the claim process moved forward. Thank you, Turnberry. Such good service should be shared with all looking for a company like Turnberry. Warrick Port
I have found Turnberry to be efficient and prompt with their payments, the service levels are excellent, a pleasure to deal with. The main benefit is that your monthly payments provide cover that you will not a nasty shock after a medical procedure or an emergency. So, in a way and to quote a cheesy TV advert you “get peace of mind” that you have done what you can to limit your exposure to medical aid excesses. I have recommended Turnberry Gap Cover to friends and I have other family who have changed to Turnberry. You need gap cover. In 2016 my partner needed a rotator cuff operation and he had to pay a shortfall of R 14 000 as we had no gap cover. He has just had the same operation on this other shoulder (2021) and Turnberry covered the entire shortfall. He has also had to go to the Emergency Department at a hospital separate incident and the Casualty benefit covered those expenses. I rate Turnberry’s services and support somewhere between outstanding and excellent. Gordon McDonald