Cover – 26th April 2022
Medical aid and gap cover are often viewed as unnecessary when people are young and healthy. But the reality is that muscular-skeletal 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.
Most-claimed, most expensive
“From 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,” says Tony Singleton, CEO of Turnberry.
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.
Shortfalls from many different places
“Often, muscular-skeletal treatments attract an upfront co-payment, which can be significant. We have paid out claims for a R32 500 co-payment related to gonarthritis or cartilage degeneration in the knee, and R38 000 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,” Singleton adds.
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.
Peace of mind for the unexpected
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. “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 for the orthopaedic surgeon and R8 374 for the anaesthesiologist,” says Leuw.
“Without my Turnberry gap cover policy, this surgery would have left me with R41 236 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,” he adds.
Protecting your physical and financial health
Many muscular-skeletal conditions attract substantial shortfalls, which can be ongoing. For example, Turnberry had a claim for idiopathic scoliosis of the thoracolumbar region which actually exceeded the overall annual limit (OAL) of R171 000 that gap cover providers were legally permitted to pay in 2021. This was made up of shortfalls of R40 356 from the neurosurgeon, R47 013 from the orthopaedic surgeon, a R35 000 sub-limit for prosthesis, a R38 000 co-payment and then R10 629 out of a R31 261 for the anaesthetists, which was short paid as the OAL was reached.
Scoliosis can also cause ongoing problems, as seen by another client who has had claims for shortfalls totalling R234 584 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 375 which included a co-payment of R32 500, sub-limit for prosthesis of R25 999 and shortfall for the orthopaedic surgeon of R19 875. For malunion of fracture, or a fracture that healed badly and had to be rebroken and reset, the shortfalls covered by Turnberry were R158 455, which included shortfalls of R28 924 for the anaesthetist, R25 034 for the plastic surgeon and R82 966 for the orthopaedic surgeon as well as a R21 500 sub-limit for the prosthesis.
“The 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,” Singleton concludes.
What is Gap Cover?
Turnberry assisted with claims for various incidents during the last few years – from an elective orthopaedic surgery for my young daughter to emergency surgeries for my wife. When my wife was diagnosed with cancer last year, the once-off payment assisted in a number of the out-of-hospital expenses. In addition, the knowledge that the expenses threshold is so much higher than the standard medical rates provided peace of mind. I have recommended Turnberry Gap Cover to our family, and reiterate that it is an essential or mandatory product. No healthy person believes critical or emergency procedures will happen. But the truth is that it can happen to anyone. The cost vs benefit is not a logical debate, without gap coverage you may end up selling assets to cover the bills. Turnberry’s services were professional, quick and efficient – ‘Peace of mind’. Mynhardt Oosthuizen – January 2022