Cancer diagnosis claims soar among 30+ age group, report says

An analysis of cancer-related gap claims paid by Sirago Underwriting Managers between 2020 and 2024 reveals a sharp rise in claims linked to initial cancer diagnoses and treatment co-payments.

Sirago, a gap cover provider underwritten by GENRIC Insurance Company Limited, says the trend highlights both the financial strain and the healthcare challenges facing South Africans.

The company examined claims under its ‘Initial Cancer Diagnosis’ benefit, which provides a lump sum payment upon the first diagnosis of malignant cancer, and its ‘Cancer Co-Pay’ benefit, which applies once medical scheme sublimits are reached and co-payments imposed.

According to Sirago, these benefits are designed to cover diagnostic tests such as PET scans, MRIs, biopsies, and blood tests, as well as immediate medication needs while treatment plans are being registered with medical schemes.

Sirago reports that Initial Cancer Diagnosis (ICD) claims rose by 150% in 2021 compared with 2020, reflecting the impact of the pandemic on preventative healthcare. By 2024, ICD claims had increased by 263% compared with 2020. The split between male and female patients is almost even, but the age profile is striking, with many first-time diagnoses occurring from the age of 30 upwards.

Martin Rimmer, CEO of Sirago, says the surge in cancer-related gap claims is deeply troubling. “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.”

He says: “Of significant concern is the huge percentage of initial cancer diagnoses, notably in the 50+ age group, and many of these happen at later stages. Later stages of cancer detection have a profound impact on 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," Rimmer says.

Sirago has also recorded a rise in “mega” gap claims, those exceeding R50 000, for shortfalls or co-payments not covered by medical schemes for in-hospital treatment. Without gap cover, members would have to pay these amounts themselves.

“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,” Rimmer says.

He says that a cancer diagnosis is both a health and financial shock. “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 its own rules and protocols for 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.”

Rimmer says that 85% of Cancer Co-Pay and ICD claims were in the 40+ age group, the most economically active years. “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,” he says.

Cancer treatment costs can run into hundreds of thousands, even millions of rands. A 20% shortfall on medical scheme benefits can translate into devastating out-of-pocket expenses, compounded by reduced income due to illness, Sirago says.

Rimmer urges consumers to work with independent financial planners to ensure their medical scheme, gap cover, critical illness, and disability insurance are aligned to provide access to quality healthcare and financial protection.

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