Our analysis of cancer-related gap claims we paid between 2020 and 2024 shows a staggering increase. The increase relates to gap claim volumes for initial cancer diagnosis, treatment co-payments and shortfalls. This cancer gap claims surge reflects growing pressure on healthcare funding.
We operate as a gap cover provider, and GENRIC Insurance Company Limited underwrites the business.
When drilling into the statistics, we analysed claims linked to our ‘Initial Cancer Diagnosis’ benefit. These claims relate to diagnostic investigations and tests for an initial malignant cancer diagnosis. In addition, we analysed our ‘Cancer Co-Pay’ benefit. This benefit applies once the medical scheme cancer sublimit is reached and a co-payment is imposed.
Initial cancer diagnosis claims
Our ‘Initial Cancer Diagnosis’ benefit provides a lump sum payment upon diagnosis of a malignant cancer. Members use this benefit to fund diagnostic investigations such as PET scans, MRIs, biopsies and blood tests. Medical schemes often impose co-payments or sub-limits on these services. In addition, the benefit supports immediate access to medication while members register treatment plans with their schemes.
- Initial Cancer Diagnosis (ICD) claims volume increased by 150% in 2021 compared with 2020. We link this rise to the aftermath of the pandemic. Preventative healthcare declined sharply, and early diagnoses of chronic diseases, such as cancer, collapsed. This trend contributed to the broader cancer gap claims surge.
- In 2024, our ICD claims volume increased by 263% compared with 2020.
- Between 2020 and 2025, ICD claims show an almost even split between male and female patients. However, the age distribution reveals more significant insights into first-time diagnoses.
| ICD – % of Claims Volume by Gender and Age Group | ||
| Age group | Female | Male |
| 0-18 | 1% | 1% |
| 19-29 | 2% | 1% |
| 30-39 | 4% | 2% |
| 40-49 | 12% | 3% |
| 50-59 | 23% | 18% |
| 60+ | 58% | 75% |
Cancer co-pay claims
We introduced the Cancer Co-Pay benefit in 2022. This benefit applies when a medical scheme cancer sublimit is reached within the benefit cycle. It also covers imposed co-payments. Furthermore, it includes co-payments for ongoing cancer treatments and biological drugs. This support continues until the medical scheme reinstates the next treatment cycle.
- Cancer co-pay claims increased by 104% in 2023 compared with 2022.
- Cancer co-pay claims increased by 130% in 2024 compared with 2022.
These increases further reinforce the cancer gap claims surge observed across the dataset.
| Cancer Co-Pay – % of Claims Volume by Gender and Age Group | ||
| Age group | Female | Male |
| 0-18 | <1% | <1% |
| 19-29 | 1% | <1% |
| 30-39 | 10% | 5% |
| 40-49 | 8% | 3% |
| 50-59 | 27% | 12% |
| 60+ | 53% | 79% |
The seriousness of these trends
The sharp increase in cancer-related gap claims is profoundly concerning, particularly within the context of this cancer gap claims surge. Cancer is highly prevalent in modern lifestyles.
The incidence of cancer, even from the 30+ age group, requires a serious reality check. This applies to both healthcare financial planning and preventative healthcare. While the pandemic delayed preventative care and increased late diagnoses, annual health checks have still not recovered.
Of significant concern is the high percentage of initial cancer diagnoses in the 50+ age group. Many of these cases occur at later stages. Late detection reduces treatment success and increases costs. In addition, rising cancer co-payment claims reflect affordability challenges. Many South Africans face financial pressure in the current economic climate. As a result, consumers often downgrade to core medical scheme plans. These plans offer lower benefits and require more out-of-pocket funding for treatment.
We have observed further evidence of this trend. Specifically, the company reports a sharp increase in ‘mega’ gap claims related to cancer. These claims refer to amounts of R50,000 or more. They cover shortfalls or co-payments not paid by medical schemes for in-hospital treatment. This pattern aligns closely with the broader cancer gap claims surge. Without supplementary gap cover, many members must fund these shortfalls themselves.
This situation often affects members on plans that pay 100% or 200% of the medical tariff rates. These members are often younger. They assume that their age and health reduce their risk. However, the increase in cancer-related claims among people aged 30+ tells a different story. Cancer does not consider age or current health status.
The financial and emotional storm no one can predict
A cancer diagnosis changes everything instantly. It affects both your health journey and your financial reality. While medical schemes provide essential coverage, significant gaps remain in cancer treatment funding.
All medical schemes typically cover the Prescribed Minimum Benefits (PMBs) cancer treatments at cost. However, not all cancers qualify as PMBs. Each scheme applies its own rules and protocols when diagnosing and managing PMBs. If a cancer does not fall within the PMB basket, members face out-of-pocket expenses.
In addition, some schemes only partially fund treatments such as biological drugs. Others do not fund them at all. Many core plans also exclude diagnostic tests like MRI and PET scans.
When you consider that 85% of Cancer Co-Pay and ICD claims occur in the 40+ age group, the impact becomes clear. These are economically active years with high financial responsibilities. If individuals must use life savings to cover treatment shortfalls, the consequences are severe. The situation worsens for those without savings.
In conclusion
Cancer treatment costs can reach hundreds of thousands or even millions of rands. Even a 20% shortfall can result in significant out-of-pocket expenses. This often occurs at a time when income declines due to illness. Therefore, it is essential to consult an independent financial planner.
You must ensure that your healthcare funding plan works as an integrated system. This includes your medical scheme option, gap insurance, critical illness cover and disability insurance.
Together, these components should provide access to quality healthcare, treatment and lifestyle protection. Work with your financial adviser to strengthen your healthcare funding strategy. Move away from a fragmented approach based on hope. Instead, build a robust financial foundation that supports your fight against cancer.
Martin Rimmer | CEO | Sirago Underwriting Managers | mail me |
