SAOPA

O&P reimbursement

Depending on the cause of the injury or medical condition, the orthotic or prosthetic devices, and the related rehabilitation services, is likely to be financed through the following avenues: (Applies to South Africa)

  • Private Funds
  • Medical Aid
  • Road Accident Fund
  • COIDA / WCA – Workmen’s Compensation Fund
  • Personal Injury Claims (medical negligence, general public negligence, Transnet)
  • Combination of the above

Reimbursement

This generally applies to individuals that do not have a medical aid and did not get injured as a result of a road accident or occupational injury; therefore there is no claim against the Road Accident Fund or Workmen’s Compensation Fund for example.

This is often individuals who need orthotic or prosthetic devices as a result of disease (such as diabetes, vascular disease or cancer) or as a result of general injury /trauma (that result in serious infection) or congenital (birth) deformity where they do not have a medical aid.

In cases like this, the individual and/or family would need to finance their orthotic or prosthetic device and rehabilitation service personally. Individuals can also 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 – such as a ticket raffle
  • Sponsorship (by individuals or companies)
  • Combination of two or more of the above.

There is a large array of medical aid schemes in South Africa and many of them do have an external medical device (orhotic or prosthetic device) benefit. The exact amount of benefit will depend on the particular Medical Aid and the specific plan within that Medical Aid. Generally, the benefit itself can range anything between R 3,000 – R 55,000 maximum – excluding Ex Gratia or PMB, both to be explained a bit later.

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


How to claim from your medical aid

  • Depending on the medical aid, your Orthotist & Prosthetist can enquire on your behalf with the medical aid what your available orthotic or prosthetic benefit is.
  • Your Orthotist & Prosthetist can send a quotation to the medical aid and await for pre-authorisation.

PMB – Prescribed Minimum Benefit

If your medical aid orthotic or prosthetic benefit is insufficient, you can 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

To apply for PMB, you contact your medical aid and ask for the necessary documentation that needs to be completed by both you and your healthcare practitioner, in case of prosthetic treatment, your Prosthetist. The medical aid will then provide you with feedback within 60 days.


Ex Gratia

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

For example; a child is born with a congenital abnormality were part of a limb is missing. The prosthetic treatment and rehabilitation costs exceed the official prosthetic benefit level, but the Ex Gratia committee may on compassionate terms decide to pay the balance between the benefit and the total prosthetic rehabilitation costs. The medical aid has no legal requirement to grant an ex-gratia payment.

If you have been injured in an accident on the South African roads, you may have a claim against the Road Accident Fund. This includes both motor vehicle (car, motor cycle, taxi, bus, truck) and pedestrian accidents.

The Road Accident Fund provides compulsory cover to all user of South African Roads. The RAF reimburse road accident victims who were seriously injured and as a result incurred medical costs, loss of employment or income and often required long term medical treatment, which of course also have financial implications.

It is generally beneficial to get a competent and experienced attorney firm to facilitate your claim against the Road Accident Fund. These firms can help you to get all the necessary forms, documentation and medical expert reports that would be needed to process your claim. In most cases, experience has shown that individuals who are represented by an attorney get better compensation as compared to direct claims handling and settlement by the Road Accident Fund itself.

In terms of an injury as a result of a road accident, the individual would be compensated in two parts – a financial reimbursement for general damages and an undertaking for future medical expenses.

  • The financial reimbursement for general damages would be for loss of income incurred since the accident, past medical expenses related to the accident, loss of income for the future (if the individual cannot work again) and also for pain and suffering as a result of the injuries sustained.
  • The Undertaking. This is an agreement between the RAF and the claimant for future medical expenses that is related to the relevant accident. These future expenses are not paid out to the claimant in cash, but rather paid as the medical expenses are incurred. In case of a serious injury, this would be for an orthotic or prosthetic device. There is however terms and conditions, for example: The RAF will generally only pay for a new prosthesis once every 5 years.

Once your case is settled and you have your official undertaking letter, you can generally go to a private practitioner of your choice within the relevant area of speciality. In most cases, the Orthotic or Prosthetic practitioner would apply for pre-authorisation on your behalf at the Road Accident Fund. Once authorisation is received (which can take anything from a couple of weeks to many months) your prosthesis fitting and rehabilitation can start.

Once the orthotic or prosthetic fitting have been done, a RAF representative (or case manager) will inspect the orhotic or prosthetic device to confirm that the treatment, clinical service and relevant orthotic or prosthetic devices have indeed been supplied. The Orthotic & Prosthetic practitioner’s account will then be paid.

The Compensation for Occupational Injuries and Diseases Act applies to all employers (casual and full-time workers) who, as a result of a workplace accident or work-related disease are injured, disabled or killed.


Under this act, there are different bodies, for example:

  • Workmen’s Compensation (WCA) – General Workers
  • The Federal Employer’s Mutual Assurance Company (FEM) – Construction Industry
  • Rand Mutual Insurance – Mining Sector & Iron, Steel, Metal Industry

Workmen’s Compensation Fund (WCA)

Workers who are affected by occupational injuries and diseases are entitled to compensation.


Steps in claiming compensation for Occupational Injuries from WCA

  • Any injury must be reported to your employer immediately. Your employer must report it to the Compensation Fund and send in the necessary forms (available on website link below).
  • Every time you visit the doctor or hospital, you need to take a WCA form with for completion by the doctor. This together with any other forms given to you by the doctor must be taken back to your employer, who will then submit it to the WCA.
  • The WCA will then award a case number to you, which you will use for all future claims and enquiries.
  • You will need to follow up with your employer on the progress of the matter.
  • Once you are awarded a claim number, you can visit your prosthetist, who will then send an application and motivation for pre-authorisation for your prosthesis to WCA

Please be aware that it can take several months for the WCA to respond to this request.

The COIDA tariff list used by Workmen’s compensation only allows for basic prosthetic components. For higher end components you may need to combine this with some other options mentioned earlier like private funding, medical aid contributions etc.

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


The Federal Employer’s Mutual Assurance Company (FEM)

FEM is licensed by the Department of Labour Compensation Fund to provide COIDA cover to employers in the Construction industry.

Steps in claiming compensation for Occupational Injuries from FEM is identical that of WCA (please see the above WCA steps)


Rand Mutual Insurance (RMA)

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 licence to administer the claims for both Class IV (Mining) and Class XIII (Iron, Steel, Metal and related industries).


Steps in claiming compensation for Occupational Injuries from RMA

  • Inform your employer immediately by means of your company’s internal procedures. Your 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 your employer who will in turn need to submit these to RMA together with your claim:
    – Certified copy of your ID or passport
    – Proof of banking details in order for us to be able to make payment directly into your bank account
    – Contact details in order for us to be able to contact and communicate with you. We require:
    – Your full residential and/or postal address
    – Your cell number
    – Your email address (where applicable)
  • Completed Section 51 document if you are under the age of 26 years or if you are a learner or trainee
  • Medical reports – your first medical report must be submitted with your original claim, however, additional medical reports are required during the course of your treatment so that we may track your progress, particularly in the case of Temporary Total Disablement (TTDs), also known as days off or temporary income replacement benefit.
  • Final assessment – this is the final document that will be submitted to RMA regarding your claim.
  • You will be awarded a claim number
  • Once you are awarded a claim number, you can visit your prosthetist, who will then send an application and motivation for pre-authorisation for your prosthesis to RMA

Medical Negligence

Although hardly ever intentional, it is an unfortunate reality that negligence by medical personnel, in the treatment of many diseases, conditions and injuries can result in the compromise (such as nerve damage) or amputation of a limb that may have been otherwise avoidable. It may not be the fault of the medical personnel, but that of the facility such as hospital or clinic and its operational personnel. It is a fair statement that medical negligence in especially governmental institutions is increasing due to lack of resources, protocols and systems and often inadequately qualified staff.

If a case of negligence is suspected against a medical facility or it’s personnel, it is advised that the services of a medical negligence attorney is obtained. The attorney, with assistance of the relevant medical experts that will be appointed, will investigate the specific case and give a professional view on whether negligence was potentially the cause for the amputation.

It should be noted that a relatively small percentage of medical negligence cases are successful as it is often difficult to prove that the alleged negligence itself caused the relevant aggravation (which in this case would be amputation) and that it would not have occurred in any case as a result of the condition, disease or injury itself.

General Personal Injury(Gunshot, Dog Bites, Assault such as stabbing etc.)

The three examples mentioned are the most common causes of severe injury that can result in the compromise of a limb (such as nerve damage that may require the use of an orhotic brace) or eventual amputation, very often as a result of vascular damage or later onset of serious infection.

A personal injury claim would be instigated against insurance of the individual/individuals/group or organisation that are represented. As a practical example, a security guard at a shopping mall accidentally fires off a firearm and injures a bystander in the leg, there would be an insurance claim against the security company for whom the security guard works or the shopping mall itself.

In case of a dog bite, a claim would be against the owner of the dog (or the owner’s personal liability insurance).

It is recommended that an experienced personal injury attorney/firm is consulted to determine if indeed such a claim would be viable and likely successful.


Metrorail/Transnet

There is a high incidence of serious injuries and amputation in the South African passenger rail network. Due to overcrowding at peak times and poor safety protocols and systems, many passengers are injured by being pushed out of trains when overfull and doors not being able to close.

Such accidents are directly a result of negligence, due to poor implementation of safety and security systems on the trains and stations.

If you have been injured while using the South African rail network, you may have a claim against Metrorail or Transnet and should consult with an experienced personal injury attorney to assess viability of such a claim.