Five-year trend shows sharp increase in cancer-related gap cover claims

An analysis of cancer-related gap claims paid by Sirago Underwriting Managers between 2020-2024 shows a staggering increase in gap claims volumes related to initial cancer diagnosis and treatment co-payments and shortfalls.

Sirago Underwriting Managers is a gap cover provider underwritten by GENRIC Insurance Company Limited. 

Drilling into the statistics, Sirago analysed the claims relating to its ‘Initial Cancer Diagnosis’ benefit – these relate to claims for the costs of diagnostic investigations and tests related to an initial diagnosis of a malignant cancer, and its ‘Cancer Co-Pay’ benefit – which is applied once the medical scheme cancer benefit sublimit has been reached within the benefit cycle and a co-payment is imposed. 

Initial Cancer Diagnosis Claims

Sirago’s ‘Initial Cancer Diagnosis’ benefit provides a lump sum payment upon the initial diagnosis of a malignant cancer. This benefit is intended to be used to fund the costs of diagnostic investigations such as PET scans, MRIs, biopsies, and blood tests which medical schemes may impose co-payments or sub-limits on, as well as immediate access to medication requirements while members are still registering their treatment plans with their medical schemes.

• Initial Cancer Diagnosis (ICD) claims volume increased by 150% in 2021 compared with 2020.  Sirago points to the aftermath of the impact that the pandemic had on preventative healthcare when the early diagnoses of chronic diseases, like cancer, simply collapsed.

• In 2024, Sirago’s ICD claims volume increased by 263% compared with 2020.
• Of the total ICD claims volume between 2020-2025, the split between male and female patients is almost even, however what is telling is the age group of people who are diagnosed with cancer for the first time. 

Cancer Co-Pay’ Claims

Sirago’s Cancer Co-Pay benefit (available from 2022) is applied once the medical scheme cancer benefit sublimit has been reached within the benefit cycle and a co-payment is imposed. This gap cover benefit incorporates co-payments for ongoing cancer-related treatments and biological drugs until the next full treatment cycle is reinstated by the medical scheme. 

• Cancer Co-Pay claims increased by 104% in 2023 compared with 2022.
• Cancer Co-Pay claims increased by 130% in 2024 compared with 2022. 

Martin Rimmer, CEO of Sirago, says that the sharp increase in cancer-related gap claims is profoundly concerning.  “Cancer is massively prevalent in our lifestyles and the incidence of cancer, even from a young 30+ age group, warrants a serious reality check both in terms of healthcare financial planning and preventative healthcare. While we know that the pandemic played a role in preventative healthcare delays which saw a spike in late cancer diagnoses, there is still a big concern that preventative, annual health checks have still not recovered. 

“Of significant concern is the huge percentage of initial cancer diagnoses, notably in the 50+ age group, and many of these happening at later stages. Later stages of cancer detection has a profound impact for patients in terms of the success and cost of their treatment. The sharp increase in cancer co-payment claims is also firmly rooted in the affordability challenges that South Africans are facing in the current economic climate.  Many consumers have been forced to buy down on their medical scheme benefits to ‘core-plans’, which in turn means access to lower benefits and more self-funding of their healthcare treatment to come from their own pockets.” 

Sirago has seen the evidence of this with a sharp uptick in ‘mega’ gap claims related to cancer - these are internally classified as claims of R50k and above for shortfalls or co-payments not paid by medical schemes for in-hospital treatment. Without having supplementary gap cover in place, many scheme members would have to fund these serious shortfalls not paid for by their medical schemes from their own pocket. 

“This is particularly the case for medical scheme members who are on scheme benefit plans that only pay out at 100% or 200% of the tariff charged by medical specialists. These tend to be younger members who assume that because they are younger and healthier, they can make do with less benefits as they are less likely to claim – however when you look at the big jump in cancer-related claims in age groups from 30+ upwards, it is very clear that cancer has no regard for age or state of health,” adds Rimmer. 

The financial and emotional storm no one can predict

A cancer diagnosis changes everything in an instant - not just your health journey, but your financial reality. While your medical scheme provides essential coverage, it's crucial to understand that even the most comprehensive medical scheme plans have significant gaps when it comes to cancer treatment.

“All medical schemes typically cover the cost of Prescribed Minimum Benefits (PMBs) cancer treatments at cost, but this doesn’t automatically mean that ALL diagnosed cancers are necessarily a PMB. Each scheme has their own rules and protocols diagnosing and managing PMBs and if the cancer detected does not form part of the PMB basket, members will most certainly be exposed to out-of-pocket expenses during their treatment.  Certain medical schemes might also only fund certain treatments partially like biologicals, if at all.  Many core plans also do not fund any of the diagnostic tests such as MRI and PET scans either. 

“When you consider that 85% of all the Cancer Co-Pay and ICD claims were in the 40+ age group – your most important economically active and financially demanding years - the financial implications are dire if you need to dig into your life savings to fund any treatment cost shortfalls – and even worse if you don’t have such savings,” explains Rimmer.

Cancer treatment costs can easily reach hundreds of thousands, sometimes millions of rands. Even a 20% shortfall on your medical scheme benefits can translate to devastating out-of-pocket expenses when you're already facing reduced income due to illness. It’s crucial to meet with your independent financial planner and make sure that your healthcare funding plan such as medical scheme option, gap insurance, critical illness and disability insurance work hand-in-glove to provide you with access to the best quality healthcare, treatment and lifestyle protection that you can afford. Work with your financial advisor to transform your healthcare funding from a patchwork of hoping-for-the-best into a robust financial foundation that supports your fight against cancer. 

(Claims statistics drawn from Sirago’s Claims Analysis, 2020-2025)