Medical claims after an accident and the RAF
If you have been seriously injured in a motor vehicle accident due to another person’s negligent driving, you could claim compensation from the Road Accident Fund. Various losses can be claimed, both past and future and these include medical or related expenses or costs incurred by your medical aid.
For more information on the basics of a Road Accident Fund claim see our article
Post-accident Medical claims and the RAF
The same basics apply for medical claims against the RAF: keep and collect and make copies of as much of the paperwork as possible. This includes reports from the specialists treating you, hospital and clinical records, invoices, accounts, proof of payment and receipts.
Medical Aid Schemes and the RAF
Be sure to speak to your medical aid after you have been involved in an accident. If you have medical aid, your medical aid scheme is likely to have made payments on your behalf for emergency treatment. As a medical aid scheme member you might be required to sign an undertaking where you agree that monies paid by your scheme will be refunded upon finalisation of your RAF claim. Thus, if you have a successful claim against the RAF and there is a payout, you have an obligation to pay this money back to your medical aid.
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. The RAF in this case is the other party from which these costs are reimbursed.
The average time until a RAF claim is settled can be lengthy and protracted. When claiming medical expenses, be sure to keep complete records of all your medical accounts, what you paid and what your scheme paid and provide this to your attorney. Your attorney and your medical aid can liaise with each other and make the necessary arrangements on your behalf.
Medical tariffs – how the RAF compensates MSPs (Medical Service Providers)
The RAF compensates emergency medical treatment as per set tariff. All medical treatments that do not fall under and cannot be classified as emergency medical treatment are compensated at a private tariff as claimed. Remember that you may be liable for co-payments if the RAF does not cover the rates or treatment in full. If for example, your case had been settled on the basis of 70% in your favour, you will be responsible for 30% of the costs yourself. Your legal team will be able to assist you with how to deal with past expenses and any money recovered as part your claim.
Claims involving future medical expenses
Future medical expense claims are reimbursed as part of an Undertaking in terms of section 17(4)(a) of the RAF Act. An Undertaking is a contract between the claimant and the RAF, in terms of which the claimant will be reimbursed for reasonable medical expenses which he/she will have to incur due to the injuries sustained in the motor vehicle accident, for the rest of his/her life.
The undertaking will cover reasonable future costs for the claimant’s injuries, which means that experimental or unproven types of treatment are not covered. The undertaking can specify types of treatment only, or cover all treatment and equipment needed as a result of the accident. A claimant may, for example, qualify for a prosthesis or a wheelchair if he/she has difficulty moving around, or for special modifications to a motor vehicle to adapt it to be driven by the claimant.
How do I know if the Road Accident fund will reimburse me?
Once you have specified quotations, contact the Undertakings Department by correspondence or per telephone, to find out whether the Fund regards the costs as both accident related and reasonable, and how much the Road Accident Fund will reimburse you, before you decide to incur these costs.
In practice the patient will have to cover the expense themselves and then submit a claim to be reimbursed by the RAF. You may reach an agreement with a service provider that they will submit a claim on your behalf, however few practices provide this indulgence to their patients. The Undertaking does not replace a medical aid as it only covers your needs related to the injuries sustained in the motor vehicle accident. Pre-existing illnesses, diseases or injuries are not covered. The undertaking also does not cover a claimant for the normal effects of ageing or the effects that other conditions may have on the injuries.
Should you have any questions about the road accident fund and your medical expenses feel free to contact Paul du Plessis Attorneys at 012 809 1588 or send an email to paul@pauldup.co.za
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