A reader wonders why her medical scheme deducted her medical expenses from her Road Accident Fund settlement.
Paseka writes: I was in a car accident and was awarded around R2 million from the Road Accident Fund (RAF). I was admitted to a private hospital and the total costs of my medical treatment came to R850 000.
My medical scheme, of which I have been a member for 13 years, has a clause that stipulates that they do not cover their members in instances where there is proof that the accident was caused by the third party. This resulted in the deduction of R850 000 from my total settlement from the RAF.
I believe that the RAF settlement was meant to enhance the quality of my life after the ordeal rather than enrich the medical scheme. Is it fair for the medical scheme to have deducted such a huge amount of money from my total settlement?
The Council for Medical Schemes replies:
A medical scheme is not allowed to evade its obligations towards a member who was in an accident, irrespective of who was at fault; however, the scheme can request its members to submit claims to the Road Accident Fund. After the RAF has made an award, the member has to pay the amount allocated towards medical expenses back to the scheme otherwise it will result in unjustified enrichment on the part of the member who would have received double benefits for the same event.
The payment from the RAF probably consists of different portions – some that were allocated to medical expenses, some to loss of income, pain and suffering etc. Even when the RAF pays out an amount that is less than the actual medical expenses the claims would have been funded in full by the scheme and the member only has to refund that portion that was paid by the RAF for medical costs to the scheme and not the full claim amount.
In summary, such a rule is allowed in the registered rules of a medial scheme as the state makes provision for claims to be submitted to the RAF which cover medical expenses. The member will not be prejudiced by the rule as the claims will still be funded and the member will not be paying anything out of pocket. In the absence of such a rule, however, a member would receive a double payment for the same medical claim.
It is important to note that schemes are obliged to fund the medical expenses resulting from a motor vehicle accident irrespective of whether a claim is lodged with the RAF or not. A scheme may also not refuse authorisation or exclude a member from benefits based on the fact that a third party like the RAF might be liable to compensate him or her for a sustained injury. The scheme must pay the bills and only then claim back from the RAF.
This article first appeared in City Press