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How can you protect yourself against medical expense shortfalls?

Accidents and illness are an unfortunate part of life, and the need to seek medical treatment is an inevitable eventuality, no matter how young and healthy you are or what life stage you are currently in. Unfortunately, with medical inflation rampant, the cost of treatment has increased dramatically.

Medical aid schemes, to keep premiums affordable, have been left with little choice other than to reduce cover and implement increasingly common co-payments and sub-limits, which can be significant. The upshot of this is that medical expense shortfalls are becoming the rule, rather than the exception, no matter what scheme or plan option you are on. Gap cover has therefore become an essential tool in helping to protect you from these shortfalls, ensuring you can get the treatment you need, when you need it, without the added financial burden of funding shortfalls out of pocket.

What is gap cover?

Gap cover is not medical insurance or a medical aid scheme, but rather a short-term insurance product that complements medical aid and helps protect you from medical expense shortfalls. These shortfalls can happen when your doctor, surgeon, or specialist charges more than the medical aid rate for in-hospital treatment, or the hospital charges co-payments for operations.

They can also occur when there are co-payments for certain treatments or procedures, such as scans and scopes, as well as when there are sub-limits for specific conditions, for example, cancer. In addition, there may be co-payments or penalties involved with using non-Designated Service Provider

(DSP) hospitals or doctors.

These must be paid out of pocket, unless you have gap cover, which will then provide some relief, up to an overall annual limit and depending on the plan type you have selected.

The gap is widening

To balance benefits with affordable contributions, medical aid schemes have had to resort to creative strategies to attempt to maximise coverage. This means more co-payments for larger sums and increased penalties for using non-DSP providers. It has also become more and more common for doctors and specialists to charge many times the medical aid rate for treatments, potentially leaving you with significant shortfalls to fund should you require treatment – these are frequently tens of thousands of Rands for a single incident or procedure, which most people simply cannot afford to fund.

Accidents happen

Sandra Mohanlal, a Turnberry client since 2020 through group gap cover from her place of employment, has seen the benefits of her gap cover add up after her husband’s knee injury led to the need for multiple treatments in hospital. In April 2022, he fell and damaged multiple structures of his knee, which required surgery. The shortfall from the Orthopaedic surgeon was

R7,009 and from the Anaesthetist the shortfall was R2,123.39. The injury then required further surgery a month later, with a shortfall of R16,895.20 from the Orthopaedic surgeon and R3,982.26 for the Anaesthetist. This added up to just over R30,000 from a single injury.

“Medical treatment is expensive, and most hospital plans only offer 100 to 200% of medical aid rates, while specialists charge many times more than this. Gap cover is essential in ensuring that you do not need to pay these shortfalls out of pocket. Unexpected medical expenses can be very stressful

– it is a relief to know that gap cover has your back,” she says.

Safeguard your financial future

Deoni Donaldson and her husband are also Turnberry clients. They are only on a very basic hospital plan with their medical scheme, so their cover is limited, and when he dislocated his wrist, there were significant shortfalls. To begin with, there was a hospital co-payment of R1,640 and then on top of this, a shortfall of R6,415.34 from the Anaesthetist and a shortfall of R14,097.48 for the Orthopaedic surgeon, for the joint ligament reconstruction he required. Deoni herself required a myomectomy and hysteroscopy for endometriosis, which saw shortfalls of R6,538.64 for the Anaesthetist, R8,177.64 for the Gynaecologist and again a R1,640 hospital co-payment. These two claims alone add up to R38,509.10, which they would have had to fund out of pocket if they had not had gap cover.

“We weighed up a lot of options, and our broker suggested that a Turnberry policy would be the best fit with our medical aid. I have never regretted the decision. I did not realise how valuable gap cover would be until we had these shortfalls – finding the money to pay for these expenses out of pocket would have been very difficult, and I am grateful to have peace of mind that these expenses were covered,” she says.

Protect yourself against medical expense shortfalls Medical aid schemes can no longer fund the full cost of treatment in many cases, so shortfalls, co-payments and sub-limits are common, and will become more so in the future. Gap cover can help to protect you against these shortfalls, by providing cover that means you will not have to fund these amounts entirely out of pocket. However, medical aid schemes and cover vary, as do gap cover policies, so it is important to talk to your broker or financial advisor to ensure you have the best cover to suit your needs.

About Turnberry Risk Management Solutions Founded in 2001, Turnberry is a registered financial services provider (FSP no. 36571) that specialises in Accident and Health Insurance, Travel Insurance, and Funeral Cover.

With extensive experience across healthcare and insurance industries in South Africa, Turnberry offers unsurpassed service to Brokers and clients.

Turnberry’s gap cover products are available to clients on all medical aid schemes, as they are independently provided and are therefore transferable in the event of a change in the client’s medical aid scheme.

Turnberry is well represented nationally, with its Head Office based in Bedfordview, Johannesburg with Business Development Managers in Cape Town and Durban. The Turnberry Team’s focus on outstanding client service comes from having extensive knowledge and experience in the financial services sector and is underwritten by Lombard Insurance Company Limited. Lombard Insurance Company Limited is an Authorised Financial Services Provider (FSP

1596) and Insurer conducting non-life insurance business.