Consumers or employees who are involved in a road accident or are injured on duty should ensure that they file a claim against the relevant compensation body as failing to do so can not only seriously deplete any savings that have accrued in their medical aid scheme but is also likely to be a stipulation of the policy.
According to Clayton Samsodien, Managing Director of Genesis Capital’s healthcare subsidiary – Genesis Healthcare Consultants – while a comprehensive medical scheme is likely to cover most of the costs involved, it is still in people’s interest to claim from the Road Accident Fund and/or Workers Compensation, in order to recover any amounts paid by the medical savings account or hospital benefit.
"Although some schemes do not accept liability for the payment of claims that can be recovered from a third party, it will pay members’ medical expenses in terms of the benefit structure of their particular product pending recovery of the funds from the appropriate Funders (third party) like the Road Accident Fund “RAF” and Workers Compensation “COID.”
Samsodien says certain scheme rules specify that the relationship between the scheme and its members must be one of utmost good faith at all times¸ therefore, in this case, the member is under duty of care to disclose all information that might have a bearing on decisions by the scheme relating to a members’ claim. “If this is not done, exclusions may be applied. Basically, members must therefore inform the scheme when a claim arises as a result of a road accident or injury on duty.”
He says for example, that rule 15.7 of Discovery Health’s medical scheme states that the member or dependants shall “be obliged to take all steps which are necessary to timeously submit a claim for compensation to the Compensations Commissioner….”
Samsodien says if someone is involved in a road accident they should inform their medical scheme to enquire as to the claims process. “Often members of medical schemes attempt to lodge a claim by themselves against the RAF. This can be both cumbersome and unnecessary as many medical schemes have a panel of approved Attorneys to assist members with the claiming process. Most importantly, Attorneys are able to claim reasonable amounts from the fund based on previous experience. A person also has to lodge a claim within 3 years.”
According to the Compensation for Occupational Injuries and Diseases Act of 1993 “COID”, all employees injured while on duty are entitled to compensation as described in the above mentioned Act.
Samsodien says any employee who has been injured whilst on duty should ensure that they report any occupational related injuries or diseases to the responsible person at their workplace as soon as possible. “Your employer has seven days to report your injury to the Compensation Commissioner. After your employer has signed the Employers Report of Accident (W.CL.2) you should receive part B, a page of the form to take to your medical practitioner. It is important to make sure that your medical practitioner’s practice is aware that you sustained the injury while on duty.
He says even if a medical scheme has covered the basic medical costs, it is still worth submitting a claim to the RAF and COID for general damages, which may not necessarily be covered by the medical scheme.
Samsodien says in the event of an accident, consumers should immediately notify their healthcare broker who can inform the scheme and assist the member to obtain legal assistance to claim. “Consumers should also ensure that they claim no matter how small, as this will ensure that funds are paid back to the medical scheme and medical savings can then be repaid.”