Future medical expenses and an RAF Section 17(4) Undertaking
If you have been in a motor vehicle accident and successfully claimed from the Road Accident Fund (RAF), your claim could include compensation for past and future medical expenses.
Many claimants ask: “Why do you have to repay Medical Aid when you had an accident and the RAF pays out? What is the reason then for having a medical aid at all?” In our previous article, “Medical claims after an accident and the RAF” we discussed the obligation of claimants to repay certain amounts recovered from the RAF to their medical aid.
You can access the article here https://pauldup.co.za/medical-claims-after-an-accident-and-the-raf/
Why doesn’t my medical aid pay for all RAF expenses?
If you have a successful claim against the RAF and there is a pay-out for the accident related expenses covered by your medical aid, you have an obligation to pay this money back.
This is because in terms of the rules of most medical schemes, medical schemes are not liable for any accident-related costs in cases where the member can institute an action against another party to have these costs covered. The RAF in this case is the other party from which these costs are reimbursed. The purpose of a medical aid is to act as a type of insurance for medical care, however the extent of their liability will depend on the plan and type of cover that a patient has, the medical tariffs and specialists that are covered, as well as whether the costs can be recovered from a responsible third party.
The purpose of a RAF Section 17(4) Undertaking
In the past the RAF had been faced with astronomically sized claims which resulted in the Fund running into financial difficulty. As part of a plan to provide fair compensation, Section 17(4) of the Road Accident Fund Act, was introduced to help regulate payment of future medical expenses.
Although estimations can be made, there is always a degree of uncertainty as to what treatment a patient will need in future and what the costs thereof will be. In the past the RAF had paid out a once-off lump sum amount which could have been too little, just enough or even too much for the actual treatment needed.
The Section 17(4) Undertaking serves as an agreement by the RAF to pay for certain medical and related services, treatment, medication and equipment which have a direct link to the injury suffered and successfully claimed for.
Why do I still need a medical aid?
The Section 17(4) Undertaking does not serve as a replacement for a medical aid. It does not cover a patient’s every medical need, only those related to the accident. Thus if you need medication for flu or treatment for cancer, the RAF will not cover this as it is necessary to show that it is directly related to the accident and injury.
How do I know what the RAF will pay for?
During your claim, your legal team will have you assessed by various medical experts. These experts will provide reports on their findings and opinions of recommended treatment and these can be used to motivate medical expenses. The RAF has a specific Undertakings department who deals with the reimbursing of injury related expenses. The recommendation is generally that the claimant must provide an invoice, motivation and proof to the relevant Undertakings department, to obtain pre-authorisation of the amount covered. The RAF will only make a payment and reimburse a claimant for actual expenses incurred, thus in most instances the claimant will have to pay the expense and then claim it back from the RAF.
If you need assistance with your claim or more information on Road Accident Fund procedure, feel free to contact us on 012 809 1588, send an email to paul@pauldup.co.za or visit our website for more resources.
Written by Dané du Plooy
Sources:
Legislation RAF Act – Road Accident Fund
Post accident medical claims and the RAF
https://www.arrivealive.mobi/post-accident-medical-claims-and-the-raf