There is a large array of medical aid schemes in South Africa and many of them allow for oththotic or prosthetic benefits. The exact amount of benefit will depend on the particular Medical Aid and the specific plan within that Medical Aid – excluding exgracia or PMB,

If the medical aid benefit is inadequate to cover all the costs for the orthotic or prosthetic rehabilitation, the patient would then need to contribute the balance of the costs.

How to claim from your medical aid

• Depending on the medical aid, an inquiry can be done on your behalf to the medical aid to inquire about available benefits.
• A quotation can be sent to the medical aid – and await authorisation.

PMB – Prescribed Minimum Benefit

Enquire about Prescribed Minimum Benefits (PMB). The PMB is a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected.

This includes:

• any emergency medical condition
• a limited set of ±270 medical conditions (which includes amputation)
• 25 chronic conditions

Contact the medical aid and ask for the necessary documentation that needs to be completed by both the person and the healthcare practitioner, in case of prosthetic treatment, the Prosthetist. The medical aid will then provide feedback (within 60-90 days).

PMB still depends on the medical aid, it does not guarantee an amount.

Exgracia In special circumstances, Medical Aids would consider contribution outside of their official benefit level. With a detailed motivation and supporting arguments, the Exgracia committee of the Medical Aid can decide to increase the benefit contribution on compassionate terms. This is often a “once off” contribution.

The RAF is a juristic person established by an Act of Parliament, namely, the Road Accident Fund Act, 1996 (Act No. 56 of 1996) as amended (”RAF Act”). It commenced operations on 1 May 1997, assuming at the time, all the rights, obligations, assets and liabilities of the Multilateral Motor Vehicle Accidents Fund.

The RAF is responsible for providing ​appropriate cover to all road users within the borders of South Africa; rehabilitating and compensating persons injured as a result of motor vehicles in a timely and caring manner; and actively promoting the safe use of all South African roads. Section 3 of the RAF Act stipulates that “the object of the Fund shall be the payment of compensation in accordance with this Act for loss or damage wrongfully caused by the driving of a motor vehicle”.

The client base of the RAF, therefore, comprises not only the South African public, but all foreigners within the borders of the country. The RAF provides two types of cover, namely personal insurance cover to accident victims or their families, and indemnity cover to wrongdoers.

The claim is lodged on a prescribed statutory claim form (Form 1 is to be used in respect of claims arising prior to 01 August 2008 and RAF 1 from 01 August 2008 onwards) which provides basic information on the claimant, the vehicles and parties involved in the collision, the date and place of accident and the amounts claimed. It also contains a medical report by the treating doctor.

This claim form is accompanied by an affidavit setting out the following:

• Full particulars of the accident,
• Police reports,
• Hospital and medical records, 
• Vouchers and documents in support of amounts claimed.
• The drivers of the vehicles involved in the collision must furnish details of the accident to the RAF on a statutory accident report form (Form 3 is to be used in respect of claims arising prior to 01 August 2008 and RAF 3 from 01 August 2008 onwards) together with information of witnesses which the RAF may request.

Once a claim is submitted, the RAF registers it on its claim system and commences with its investigations. The RAF determines whether the claim is valid (i.e. was there a road accident, does it comply with statutory provisions, was it submitted in time, etc.) and what the merits of the case are (i.e. the degree of fault, blame or negligence to be ascribed to the drivers of the vehicles and the claimant respectively). The quantum is also determined (i.e. the amount of the damages or losses suffered).

​​​If a claim is incomplete, the RAF calls for additional information and supporting documentation to enable it to better assess the matter.

If the claim arose after the 31 July 2008 and general damages are claimed, a Serious Injury Assessment Report (RAF 4) must be submitted to the RAF confirming that the injury sustained is serious for the purposes of the Act.

Steps in claiming from WCA

Any injury must be reported to the employer immediately. The employer must report it to the Compensation Fund and send in the necessary forms.

All visits to the doctor or hospital, a WCA form is taken with for completion by the doctor. This together with any other forms given by the doctor must be taken back the employer, who will then submit it to the WCA.

The WCA will then award a case number, which will be used for all future claims and inquiries.

The Follow up with the employer on the progress of the matter is done by the person self.

Once a claim number has been granted, the person can be seen by a Medical Orthotist Prosthetist, who will then send an application and motivation for authorisation for the required device to WCA

Please be aware that it can take more than 5 months for the WCA to respond to this request and the COIDA tariff list used by Workman’s compensation only allows for basic device components.

For more information on the topic and to view all the relevant forms please visit the Department of Labour’s website: www.labour.gov.za

COID (Compensation for Occupational Injuries and Diseases) is a government body that compensates workers who have been injured at work or who have contracted a disease (schedule 3 of COID Act) at work. Since August 2014 the reporting system to COID changed to an online system called Umehluko.

All businesses need to understand the logistical processes, how COID operates, how the registration system works, and the applicable tariffs. COIDA is there to safeguard workers when they are injured and to make sure that businesses support their compensation by paying their tariffs.

The Compensation for Occupational Injuries and Diseases Act (COIDA) 130 of 1993 sets out the legal requirements for tariffs, compensation and the limitations for claims for workers who are injured, or who contract diseases while they’re at work.

According to the Act, workers who suffer from a work-related disease or injury, have the following rights:

• The right to full free medical attention, including free transport to the hospital.
• Compensation for loss of income due to workplace injury or disease (temporary disability).
• Compensation for permanent loss of normal body functioning following a workplace injury or disease (permanent disability).
• Benefits payable to family in the case of the death of a worker due to workplace injury or disease.
• Increased compensation should the cause of the workplace injury or disease has arisen out of negligence on the part of the employer or fellow employee.
• Compensation is also payable if the workplace injury or disease was caused by a third party but arose during the course of the duties of the employee.

The Rand Mutual Assurance Limited was established in order to administer Workman’s Compensation Insurance benefits to workers injured in the course of their employment to the South African Mining Sector. RMA has the license to administer the claims for both Mining and Iron, Steel, Metal and related industries.

Steps in claiming compensation for Occupational Injuries from RMA

• Inform the employer immediately by means of the company’s internal procedures. The employer must report the incident to RMA within seven days from the date of the accident for all injuries, or within 14 days of diagnosis of disease.
• Submit the following documents to the employer who is required to submit these to RMA together with the claim

– Certified copy of the persons ID or passport

– Proof of banking details

– Contact details.

The Medical Orthotist Prosthetist Requires.

– Full residential and/or postal address

– Cell number

– Email address

• Completed Section 51 document (Only for an individual under the age of 26 years or the person is a learner or trainee
• Medical reports (The first medical report must be submitted with the original claim, however, additional medical reports are required during the course of the treatment so that progress can be tracked, particularly in the case of Temporary Total Disablement (TTDs), also known as days off or temporary income replacement benefit.
• Final assessment (final document that will be submitted to RMA regarding the claim.)
• Person will be awarded a claim number
• Once a claim number has been awarded, the person may see a Medical Orthotist Prosthetist, who will then send an application and motivation for authorisation for the device to RMA

Private funds commonly apply to a person that does not have a medical aid and did not get injured in a road accident or occupational accident; thus there is no claim to the Road Accident Fund or Workman’s Compensation Fund. 

These individuals who injure or loses a limb as a result of disease (such as diabetes, vascular disease or cancer) or as a result of general injury /trauma or congenital deformity where they do not have a medical aid. 

In cases like this, the individual and/or family would need to finance their device personally. 

The patient has the responsibility to get financial support through:

• Personal funds (such as savings, bank credit or loans, selling assists)
• Contributions and donations from family members and friends
• Fund raising events
• Sponsorship by individuals or companies