When your heart needs help, gap cover can save your pocket

Tony Singleton

HEART disease is one of the leading causes of death in our country. While heart problems are covered as prescribed minimum benefits (PMBs), the voluntary use of a non-designated service provider can result in a shortfall, and these are often sizable. There are many different types of heart disease, which require different treatment and have different risks and outcomes. Congenital heart disease is something children are born with and nothing can be done to prevent it. But, while some risk factors are out of our control, including age, sex, genetics and family history or heart disease, the vast majority of heart diseases and strokes (up to 80%) can be prevented. It is essential to control risk factors around lifestyle, such as stress, smoking, nutrition, body weight, cholesterol and blood pressure, and by managing other diseases such as diabetes.

Screening and monitoring these factors can help to identify problems early on, such as high cholesterol, so that they can be addressed before they can cause severe disease.

Don’t let heart disease ruin you Most heart conditions are PMBs, which means that, if you make use of a designated service provider (DSP) to obtain treatment, it will be fully covered by your medical scheme.

The exception is if there is a life-threatening emergency where you could not select a DSP, in which case the claim will be funded in full until you are stabilised.

You will then need to be moved to a DSP if you want the medical scheme to continue to fully fund the treatment. If a DSP is not used, you will be subject to medical expense shortfalls.

However, while heart diseases are typically PMBs, there are certain elements of treatment that may be subject to sub-limits.

For example, the stents used to open blocked coronary arteries are considered to be prosthesis, as are pacemakers, which means medical schemes may only fund a portion of the cost. There may also be shortfalls with regard to doctors and surgeons, which can be extremely costly. For example, we saw a claim in February for a cardiothoracic surgeon, for the treatment of acute ischaemic heart disease, that was charged at R141 862. The medical scheme paid R51 681, leaving a shortfall of R90 18, which would have fallen to the member to pay, had they not had gap cover. Another claim from October 2020 for unstable angina and atherosclerotic heart disease saw a member experience a shortfall of R71 383 for the cardiothoracic surgeon, R22 500 for the anaesthetist and R16 277 for the cardiologist, a total shortfall of R110 160.

Beyond the emergency

Heart disease, apart from often resulting in expensive emergency surgical procedures, also requires long-term management with medication. Members also need to ensure they register chronic conditions, including high cholesterol and blood pressure, to make sure these are covered. The basket of care for PMB conditions like heart disease includes diagnosis, the medication required for maintenance, as well as consultation and blood tests needed to confirm that the disease is being well regulated.

However, prevention is always better (and less costly) than cure. To truly safeguard heart health, and financial wellbeing, we need to ensure we control all of the risk factors we can.

This includes not smoking, minimising stress, eating a healthy diet, and getting enough exercise.

Heart disease is a leading killer across the globe, and in South Africa as well, but most of the time it can be prevented.

Tony Singleton is the chief executive of Turnberry, a gap cover provider.