Brian Harris, General Manager Operations at Turnberry Management Risk Solutions

FA News – June 2024

As medical inflation has continued to rise and the cost of medical procedures has increased, medical schemes are faced with the juggling act of keeping premiums affordable, while still offering adequate cover.

In addition, new procedures such as robotic-assisted surgery and new cancer drugs offer better outcomes, but at a greatly increased cost. As a result, we are seeing increased medical expense shortfalls, particularly when it comes to specialists, as well as increased co-payments and sub-limits. The upshot of this, for the consumer, is vastly increased out-of-pocket expenses, which is why Gap cover has become critical.

Given the increase in both the frequency and Rand value of claims, having Gap cover in place has never been more important.

The state of Gap cover

The frequency and value of Gap cover claims have increased dramatically over the years as the gap between what medical schemes cover and what specialists and providers charge continues to widen.

In 2023, Turnberry paid out R119 968 466 in claims, proportionately this accounted for 56% of the total claims, with medical schemes covering the remaining 44%. This figure includes a significant number of high-value claims, with many of them exceeding    R100 000. Three of the highest claims in 2023 were R129 193 60 for heart disease, R128 485 43 for a nasal polyp, and R125 735 08 for a spinal fusion surgery.

These are figures paid out over the course of a single year and for a single diagnosis. Gap cover policies are subject to an overall annual limit (OAL) per individual covered by the policy, and this limit is increased in April each year and is currently R198 660 43 per insured person. This limit resets every year, which means that over a lifetime, the amount paid out for individuals and families is far higher. At Turnberry, the top three lifetime claims are figures in the hundreds of thousands of Rands: R502 983, R450 225, and R414 331 respectively.

 What does this mean?

The most common procedures we see as a Gap cover provider are spinal disc problems, cancer, heart disease, cataract surgery and maternity, and these claims can and often do exceed R100 000 per incident. These figures highlight the fact that in South Africa, Gap cover is essential for anyone wishing to access private healthcare without potentially incurring significant out-of-pocket expenses.

The reality is that even young and healthy people could need costly medical procedures, and as they age and life stages change, medical needs do too. Accidents can happen to anyone, regardless of age, and injuries related to sports and physical activity are also common in younger age groups. Starting a family inevitably involves increased medical expenses, from pregnancy and childbirth to raising children who frequently need medical attention. Health issues related to stress are also on the rise, including anxiety and depression. In later life stages, chronic diseases like high blood pressure, high cholesterol, and prediabetes become more common. Cancer can strike anyone and is increasingly seen in younger population groups.

Brokers should engage with their clients

The cost of quality medical care continues to increase, and medical expense shortfalls as well as co-payments and sub-limits are becoming more and more common, at higher amounts. This means that any medical treatment, regardless of a person’s age or life stage, can end up costing tens of thousands of Rands out-of-pocket. Over a lifetime, these sums could potentially add up to millions.

It is important for brokers to engage with their clients to make sure they have the right medical scheme cover in place first, and then to supplement this with appropriate Gap cover, to ensure that they are able to access the medical care they need without the financial burden of out-of-pocket expenses resulting from medical expense shortfalls, co-payments and sub-limits.

What is Gap Cover?

Client Testimonials

I hereby want to thank you for the excellent service from Turnberry Gap Cover.   With every call that I have made to Turnberry I was served with patience, kindness and very friendly and everyone that I have spoken to were helpful.   I highly recommend anybody to make use of the Turnberry Gap Cover.  Out of 10 I will surely give Turnberry 10.    Hannes Kroukam 

What a great experience I had with Turnberry, they were so professional and most of all so speedy to settle my claim. Very seldom does one get this kind of service, I can really recommend them with a good heart.     Carol Pagani