Injuries can arise under various circumstances in life. It can be a simple fall at home. A motor vehicle accident. An assault. Or an injury sustained in the workplace. Medical aid does not limit payout based on where or when you sustained an injury but they will need to know the details. You as a medical aid member have the protection of knowing that essential medical services are paid for by your scheme up to a certain limit every year. Unfortunately not every South African has medical aid and may have to depend on government agencies such as the Compensation Commissioner (workmen’s compensation) or the Road Accident Fund to afford private medical care in certain instances.
However, with the Road Accident Fund (RAF) under severe financial strain and Workmen’s Compensation sitting with a backlog of some 120,000 invoices as of the beginning of 2013, many medical service providers are refusing to deal with these agencies. This leaves the worker in a dilemma. Do I depend on workmen’s compensation for my IOD claims or do I turn to my medical aid for cover in the private health sector? Your doctor is not obliged to accept, deal with or wait for payment from Compensation Commissioner and depending on the availability of services in your area, you may have to turn to public health care for treatment.
Medical Aid vs Workmen’s Compensation
Some employees are at times confused as to the difference between workmen’s compensation and medical aid. It is important to first understand that these are two different types of cover. Medical aids are privately run non-profit organisations that pay out for health care services for its members. Workmen’s Compensation is a government-run fund that pays for the medical services related to injury and disease sustained or contracted within the workplace.
Workmen’s compensation is an essential benefit that employers have to pay for their staff. Medical aid is not. Your employer is not obliged to provide you with a medical aid subsidy but many medium to large enterprises do offer this benefit to their staff as an incentive. If you employer has paid for workmen’s compensation for you and you sustain an injury on duty (IOD), your employer cannot be held liable for the medical bills related to this injury. Instead the Competition Compensation has to pay for it. This is where a medical aid is more advantageous.
These are the key differences between medical aid and Workmen’s Compensation when it comes to paying the medical bills.
Medical Aid and IOD
When you sign up for medical aid, the contract is such that the scheme will pay for legitimate, necessary and essential medical services for you as the member provided that there are no waiting period restrictions and other exclusions in place. Your medical aid is there to take care of these medical aid bills up to a certain limit and with a specific tariff guideline as stipulated by the National Health Reference Price List (NHRPL). If you are injured on duty, your medical aid is likely to cover you for the associated healthcare costs. However, your medical aid needs to be informed that this injury was sustained while you were on duty.
You should still ensure that your employer submits an injury or accident report to the Compensation Commissioner and that the workmen’s compensation claim is filed within the stipulated time period. Your medical aid may not pay for all services and your limit for the year will be consumed to some degree for the IOD services. Therefore, compensation for the IOD claim may be necessary even if you have medical aid which has covered the costs in part or full for the injury you sustained. It is also important to clarify with your medical aid as to their stand on the bills they paid for your medical care and the reimbursement from the Compensation Commissioner.
The issue about whether you or your scheme are entitled to be reimbursed for expenses that were paid privately when it was an injury on duty needs to be carefully investigated. While you may have some difficulty in dealing with the Compensation Commissioner’s office, your medical aid will be able to provide you with the necessary advice as to what the next step is on the matter. You will then have to ensure that the necessary forms and reports are completed by your employer and medical doctor in order to facilitate the claim for workmen’s compensation.