After a road accident, it’s common to need expensive medical care. Private hospitals and healthcare practitioners usually demand prompt payment – but a claim against the Road Accident Fund (RAF) can take several years to finalise. So what does the law say about claiming expenses from both the Road Accident Fund and medical aid?
DSC Attorneys partner, Kirstie Haslam, says that it is legal to claim compensation for road accident-related medical costs from both your medical aid scheme and the Road Accident Fund (RAF).
However, she points out that you’re generally required to refund the medical aid scheme for expenses that are subsequently recovered from the RAF.
“If the RAF does not compensate you for particular medical expenses, your medical aid scheme remains liable for those costs, depending on your level of cover and available benefits,” she explains.
“It’s worth noting that an RAF payment may be made up of separate amounts, allocated as compensation for different categories of damages. Examples are medical expenses, loss of income, and/or pain and suffering. This will depend on the circumstances surrounding a claim.”
As a medical aid member, Haslam says that you’re responsible for paying back only the amount received from the RAF specifically for medical expenses and that this applies even if the RAF compensation for medical expenses is less than the amount paid out by your medical aid scheme.
Different approaches by South African medical aids
Haslam says that medical aid schemes don’t all take a uniform approach to the recovery of accident-related funds from the RAF.
“Before settling accident-related claims, some medical aid schemes require members to provide a written undertaking to claim their medical expenses from the RAF and then reimburse the schemes. They put the onus on members to initiate claims on their behalf.”
She explains that some medical aid schemes use their own attorneys to claim medical expenses from the RAF. For instance, Libcare contracts the Medical Aid Recovery Unit of Alexander Forbes to process claims submitted to the RAF for reimbursement of funds paid by Libcare Medical Scheme.
“As an exception to the rule, at least one scheme – the Government Employees Medical Scheme (GEMS) – has chosen not to lay claim to medical expenses that its members recover from the RAF,” she adds.
The issue of legal costs when refunding medical expenses
Haslam says that some medical aid schemes allow their members to deduct legal costs incurred during the RAF claims process from the amount that must be refunded to them.
“Other schemes require undertakings from members to repay accident-related medical expenses in full, regardless of legal costs they incur,” she says.
Right of medical aids to terminate membership
According to the Medical Schemes Act of 1998, a medical aid scheme has the right to terminate membership if a member fails to repay a debt owing to the scheme.
In 2011, a Council for Medical Schemes ruling upheld this principle in relation to RAF compensation owed to a medical aid scheme.
In R Bobroff & Partners obo Mr. M Bellon v. Discovery Health Medical Scheme, the Council found in favour of Discovery Health, and termination of membership was upheld.
Pursuing an RAF claim is a lengthy, complex process therefore Haslam says that it is not a good idea to submit a RAF claim without professional legal representation.