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Cover – 26th April 2022<\/p>\n
Medical aid and gap cover<\/a> are often viewed as unnecessary when people are young and healthy. But the reality is that muscular-skeletal<\/a> conditions, or those affecting the bones, muscles, tendons, ligaments and soft tissues, can happen to people of any age. While some are degenerative and affect people more as they advance in age, accidents do not discriminate, and they can come with hefty medical expenses. In addition, procedures related to the muscular-skeletal system are frequently not fully covered by medical schemes, leaving people with significant medical expense shortfalls that need to be paid out of pocket. Gap cover gives everyone, young and old, peace of mind that they are protected from this financial burden.<\/p>\n \u201cFrom the point of view of a gap cover provider, muscular-skeletal conditions are not only some of the most expensive claims we see, they are also the most frequent conditions claimed for because the category is so broad. Claims range from hip bone fractures and replacements to lower back pain, shoulder inflammation like rotator cuff tendonitis to ligament tears or sprains and herniated discs, and even congenital conditions like scoliosis,\u201d says Tony Singleton, CEO of Turnberry.<\/p>\n The main reason for claims related to muscular-skeletal conditions is the way these are covered by medical aid. As always, medical schemes are required by law to fully cover treatment related to Prescribed Minimum Benefits (PMBs) within certain criteria.<\/p>\n \u201cOften, muscular-skeletal treatments attract an upfront co-payment, which can be significant. We have paid out claims for a R32\u00a0500 co-payment related to gonarthritis or cartilage degeneration in the knee, and R38\u00a0000 co-payment for surgery related to idiopathic scoliosis. Many people are also not aware that most medical schemes impose co-payments on joint replacement surgery, with some being as high as 25% of the hospital account. In addition to this, the replacement joints are classified as internal prosthesis and these typically have a maximum Rand value that will be covered by the medical scheme. This Rand value limitation imposed by the medical scheme is referred to as a sub-limit. In instances where the cost of the internal prosthesis exceeds the medical schemes sub-limit, members can be left out of pocket if they do not have a gap cover product with sub-limit cover,\u201d Singleton adds.<\/p>\n When it comes to accidents, medical expense shortfalls can come from many different places. These may include the fees associated with visiting the casualty department, shortfalls from doctors, surgeons, specialists and anaesthesiologists who charge many times the medical aid tariff, sub-limits from internal prosthesis, and even the cost of using a non-designated service provider (DSP) hospital. Without gap cover, any muscular-skeletal condition can generate significant out-of-pocket medical expense shortfalls and create a heavy financial burden.<\/p>\n Len Leuw, a Turnberry customer for 15 years, has had several claims over the years and recently underwent a hip replacement for coxarthrosis, or osteoarthritis of the hip joint. \u201cBefore 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\u00a0932 for the orthopaedic surgeon and R8\u00a0374 for the anaesthesiologist,\u201d says Leuw.<\/p>\n \u201cWithout my Turnberry gap cover policy, this surgery would have left me with R41\u00a0236 in shortfalls, which I would have had to cover out of my own pocket. Very few people have this type 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 lot of 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,\u201d he adds.<\/p>\n Many muscular-skeletal conditions attract substantial shortfalls, which can be ongoing. For example, Turnberry had a claim for\u00a0idiopathic scoliosis of the thoracolumbar region which actually exceeded the overall annual limit (OAL) of R171\u00a0000 that gap cover providers were legally permitted to pay in 2021. This was made up of shortfalls of R40\u00a0356 from the neurosurgeon, R47\u00a0013 from the orthopaedic surgeon, a R35\u00a0000 sub-limit for prosthesis, a R38\u00a0000 co-payment and then R10\u00a0629 out of a R31\u00a0261 for the anaesthetists, which was short paid as the OAL was reached.<\/p>\n Scoliosis can also cause ongoing problems, as seen by another client who has had claims for shortfalls totalling R234\u00a0584 for treatments between 2019 and 2021. In the case of cartilage degeneration or primary gonarthrosis, Turnberry has paid out many claims, one of them totalling R78\u00a0375 which included a co-payment of R32\u00a0500, sub-limit for prosthesis of R25\u00a0999 and shortfall for the orthopaedic surgeon of R19\u00a0875. For malunion of fracture, or a fracture that healed badly and had to be rebroken and reset, the shortfalls covered by Turnberry were R158\u00a0455, which included shortfalls of R28\u00a0924 for the anaesthetist, R25\u00a0034 for the plastic surgeon and R82\u00a0966 for the orthopaedic surgeon as well as a R21\u00a0500 sub-limit for the prosthesis.<\/p>\n \u201cThe long and short of it is that muscular-skeletal conditions can affect anyone, regardless of overall health or age, and the medical shortfalls can be significant. Specialists typically charge three to five times the medical aid rate, and this can run to many thousands of Rands. Gap cover is invaluable in helping to ease the financial strain these would otherwise cause. Understanding your medical aid cover and having the right gap policy to augment it is essential and one should seek assistance from their financial advisor in order to obtain the correct gap cover offering to meet your needs,\u201d Singleton concludes.<\/p>\nMost-claimed, most expensive<\/h2>\n
Shortfalls from many different places<\/h2>\n
Peace of mind for the unexpected<\/h2>\n
Protecting your physical and financial health<\/h2>\n