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
Hi There,
I was in an motor vehicle accident and taken to hospital by an Ambulane, it was an emergency and I was incapacitated and in need of medical attention. Discovery denied authorisation for admissed and is adamant that pre-approval was required and there is no laws governing PMB’s and admission is solely at their discretion. The hospital is now seeking legal action against me for non payment and discovery just ignores my request for arbitration. Is there anything I can do legally?
Yes, you can lodge a complaint with the Council of Medical Schemes. https://www.medicalschemes.co.za/consumer-assistance/complaintsprocedure/
Emergency rooms are not part of the hospital so are not necessarily covered by a hospital plan. But if it is an emergency under PMBs (and the correct codes were used by the ER) then the scheme should pay for it.
Good day. I have a question based on this case. I have recently been involved in a motor vehicle accident. A third party did cause the accident as a truck drove into the back of me at a stationary position waiting for a traffic light to change from red. My Medical Aid has short paid on a number of the medical bills received this far although I am a paid up member with them including consultations with the Orthopaedic Surgeon. They then sent me a declaration letter of undertaking to refund them should I do a claim against the third party or an RAF claim. I think they have got a cheek!! They have short paid leaving me out of pocket for a large sum of money and then still want to claim! I have to pay both medical bills and legal bills to do the civil matter against the third party. Do I therefore have a right to deduct these fees and surely they are liable to pay all costs for this matter until a refund is secured? Could you kindly advise your opinion? Thank you so much in advance
I will need to ask a medical schemes expert on the rules around this. Which scheme?
Hi. My question is a certain portion of the money we spend on fuel goes to Raf. This is for claims like this and the medical aid provider is not contributing to this and effectively should not be able to claim on payments received.
The principle is that with insurance you cannot be paid twice for the same event. So you would have to decide whether to claim through your medical aid or RAF