Depending on the cause of the injury or medical condition, the orthotic or prosthetic devices and the related rehabilitation services are likely to be financed through the following avenues (this applies to South Africa):
- Private funds
- Medical aid companies
- Road Accident Fund
- COIDA / WCA – Workmen’s Compensation Fund
- Personal injury claims (medical negligence, general public negligence, Transnet)
- A combination of the above
This generally applies to individuals that do not have a medical aid and did not get injured as a result of a road accident or occupational injury. Therefore, there is no claim against, for example, the Road Accident Fund or Workmen’s Compensation Fund.
Individuals without a medical aid may need orthotic or prosthetic devices as a result of disease (such as diabetes, vascular disease or cancer) or as a result of general injury or trauma caused by serious infection or a congenital (birth) deformity.
In cases like these, the individual and/or family would need to finance their orthotic or prosthetic device and rehabilitation service themselves. Financing options to consider:
Personal funds (such as savings, bank credit or loans, or selling their assets)
Contributions and donations from family members and friends
Fund-raising events such as a ticket raffle
Sponsorship by individuals or companies
A combination of the above.
There is a large array of medical aid schemes in South Africa, many of whom have an external medical device (orthotic or prosthetic device) benefit. The exact amount of the benefit will depend on the particular medical aid and the specific plan within that medical aid. Generally, the benefit itself can range anything between R3,000 and a maximum of R55,000, excluding ex gratia or PMB, both to be explained below.
If the medical aid benefit is insufficient to cover all the costs of the orthotic or prosthetic device and rehabilitation services, the patient would need to contribute the balance of the amount.
How to claim from your medical aid
Depending on the medical aid, your orthotist or prosthetist can enquire on your behalf from the medical aid what your available orthotic or prosthetic benefit is.
Your orthotist or prosthetist can send a quotation to the medical aid and wait for pre-authorisation.
PMB – Prescribed minimum benefit
If your medical aid's orthotic or prosthetic benefit is insufficient, you can enquire about the prescribed minimum benefits (PMB). The PMB is a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected.
any emergency medical condition
a limited set of ±270 medical conditions (which includes amputation)
25 chronic conditions
To apply for PMB, you contact your medical aid and ask for the necessary documentation. This documentation must then be completed and submitted by both you and your healthcare practitioner – in the case of prosthetic treatment, your prosthetist. The medical aid will then provide you with feedback within 60 days.
In special circumstances, medical aids would consider a contribution outside their official benefit level. With a detailed motivation and supporting arguments, the ex gratia committee of the medical aid can decide to increase the benefit contribution on compassionate terms. This is often a 'once off' contribution.
For example, a child may be born with a congenital abnormality where part of a limb is missing. The prosthetic treatment and rehabilitation costs exceed the official prosthetic benefit level, but the ex gratia committee may decide to pay the balance between the benefit and the total prosthetic rehabilitation costs on compassionate terms. Medical aids are not legally required to grant ex gratia payments.
If you have been injured in an accident on the South African roads, you may have a claim against the Road Accident Fund. This includes both motor vehicle (car, motor cycle, taxi, bus, truck) and pedestrian accidents.
The Road Accident Fund provides compulsory cover to all users of South African roads. The RAF reimburses road accident victims who were seriously injured and as a result have incurred medical costs and/or loss of employment or income and who often require long-term medical treatment, which, of course, also has financial implications.
It is generally beneficial to get a competent and experienced firm of attorneys to facilitate your claim against the Road Accident Fund. These firms can help you to get all the necessary forms, documentation and medical expert reports that would be needed to process your claim. In most cases, experience has shown that individuals who are represented by an attorney get better compensation as compared to direct claims handling and settlement by the Road Accident Fund itself.
In terms of an injury as a result of a road accident, the individual would be compensated in two parts – a financial reimbursement for general damages and an undertaking for future medical expenses.
The financial reimbursement for general damages would be for loss of income incurred since the accident, past medical expenses related to the accident, loss of income in the future (if the individual cannot work again) and pain and suffering as a result of the injuries sustained.
The RAF will come to an agreement with the claimant regarding future medical expenses that are related to the relevant accident. This is called the 'RAF undertaking'. These future expenses will not be paid out to the claimant in cash; rather, payments will be made as the medical expenses are incurred. In the case of a serious injury, this may include an amount for an orthotic or prosthetic device. However, there are terms and conditions. For example, the RAF will generally only pay for a new prosthesis once every five years.
Once your case has been settled and you have received your official undertaking letter, you can generally go to a private practitioner of your choice within the relevant area of speciality. In most cases, the orthotic or prosthetic practitioner would apply for pre-authorisation on your behalf at the Road Accident Fund. Once authorisation has been granted (which can take anything from a couple of weeks to many months), your prosthesis fitting and rehabilitation can start.
Once the orthotic or prosthetic fitting has been completed, an RAF representative (or case manager) will inspect the orthotic or prosthetic device to confirm that the treatment, clinical service and relevant orthotic or prosthetic devices have indeed been supplied. The orthotic and prosthetic practitioner’s account will then be paid.
The Compensation for Occupational Injuries and Diseases Act applies to all employers of casual and full-time workers who, as a result of a workplace accident or work-related disease, are injured, disabled or killed.
There are different bodies under this act, for example:
Workmen’s Compensation Fund (WCF) – General workers
The Federal Employer’s Mutual Assurance Company (FEM) – Construction industry
Rand Mutual Insurance – Mining sector and iron, steel and metal industry
Workmen’s Compensation Fund (WCF)
Workers who are affected by occupational injuries and diseases are entitled to compensation.
Steps in claiming compensation from WCF for occupational injuries
Any injury must be reported to your employer immediately. Your employer must report it to the Compensation Fund and send in the necessary forms (available on website link below).
Every time you visit the doctor or hospital, you need to take a WCF form with for completion by the doctor. This, together with any other forms given to you by the doctor, must be taken back to your employer, who will then submit it to the WCF.
The WCF will then award a case number to you, which you will use for all future claims and enquiries.
You will need to follow up with your employer on the progress of the matter.
Once you are awarded a claim number, you can visit your prosthetist, who will then send an application and motivation for pre-authorisation for your prosthesis to the WCF.
Please be aware that it can take several months for the WCF to respond to this request.
The COIDA tariff list used by the Workmen’s Compensation Fund allows only for basic prosthetic components. For higher-end components you may need to combine this with some other options mentioned earlier, such as private funding and medical aid contributions.
For more information on the topic and to view all the relevant forms, please visit the Department of Labour’s website: www.labour.gov.za
The Federal Employer’s Mutual Assurance Company (FEM)
FEM is licensed by the Department of Labour Compensation Fund to provide COIDA cover to employers in the construction industry.
Steps in claiming compensation for occupational injuries from the FEM are identical to those of the WCF (please see the WCF steps above).
Rand Mutual Assurance (RMA)
Rand Mutual Assurance Limited was established in order to administer workmen’s compensation insurance benefits to workers injured in the course of their employment by the South African mining sector. The RMA has a license to administer both Class IV (mining) and Class XIII (iron, steel, metal and related industries) claims.
Steps in claiming compensation for occupational injuries from the RMA
Inform your employer immediately by means of your company’s internal procedures. Your employer must report the incident to the RMA within seven days from the date of the incident for all injuries, or within 14 days of diagnosis of a disease.
Submit the following documents to your employer, who will in turn need to submit these to the RMA, together with your claim:
– Certified copy of your ID or passport
– Proof of banking details in order for payment to be made directly into your bank account
– Contact details. We require:
– Your full residential and/or postal address
– Your cell number
– Your email address (where applicable)
Completed Section 51 document if you are under the age of 26 years or if you are a learner or trainee
Medical reports – your first medical report must be submitted with your original claim; however, additional medical reports are required during the course of your treatment so that your progress may be tracked, particularly in the case of temporary total disablement (TTDs), also known as a days off or temporary income replacement benefit.
Final assessment – this is the final document that will be submitted to the RMA regarding your claim.
Once you have received a claim number, you can visit your prosthetist, who will then send an application and motivation for pre-authorisation for your prosthesis to the RMA.