Tag: Road Accident Fund

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Angry Doctors Write to Minister About Unpaid Road Accident Fund Bills

On By ModernMedia

“We implore you to intervene,” medical experts say to Barbara Creecy

By Tania Broughton

A group of more than 70 experts from all branches of medicine say they are all owed money for professional services from the Road Accident Fund – some for as long as seven years.

They have now written to Minister of Transport Barbara Creecy asking for her urgent intervention in what they say is a “disastrous situation”.

“We implore you to intervene and install a leadership in the RAF which is able to carry out its proper functioning with integrity and honesty … we are hopeless and tired,” they said in a letter to the minister.

The letter to Minister Creecy, dated 12 July, was a follow-up to one written in early June to the previous minister Sindisiwe Chikunga. There was no response to that.

Since then, dozens more specialists, including surgeons, psychologists and occupational therapists – who are collectively owed more than R150-million – have added their signatures to the document.

But the fund says it owes them nothing.

“The same people rehash this topic every time there’s a new Minister of Transport,” RAF head of corporate communications, McIntosh Polela said.

He said the experts had not been appointed by the fund but “allegedly by its former panel of attorneys”. The Service Level Agreement with the attorneys specifically stated that medical experts could only be engaged upon written authorisation of the fund. And the fund would not be liable for any fees charged without this authorisation.

He said the vast majority of the experts’ unpaid claims had not been authorised by the fund. This was due to the negligence of former panel attorneys.

In the letter to Creecy, clinical psychologist Monique Kok said the expert appointments were legal.

And, she said, their reports were being used in courts to assist in settling matters.

The fund, she said, was “finding new and cunning ways of explaining and nullifying the expert’s authority to have performed such assessment”.

She said each assessment had been done after some form of written instruction, either from the RAF directly or their panel of attorneys.

“The experts have never acted on their own accord and gone out and somehow magically found the current claimants and performed assessments that cost time and resources without instruction from the RAF or their attorneys.”

Kok said the fund’s refusal to pay their invoices had had a dire impact with some going out of business and losing their homes.

In the follow-up letter to Creecy, psychologist Chris Sampson said the experts wanted a meeting with the minister.

“We have diligently serviced the public for many years by assisting the RAF and the courts in determining appropriate compensation for claimants who were injured in serious motor vehicle accidents.

“It would appear that the organisation (and its leader’s) treatment of its own appointed experts gives us the impression that it has been allowed to become a law unto itself and from court cases it further appears that it refuses to pay claimants, experts or abide by court orders.”

Sampson said the experts conducted “painstaking investigations” and did extensive reports which were being used by the fund and yet were waiting seven years later to be paid.

They had paid out of their own pockets the significant costs of translators, transcribers, equipment and testing material.

“We believe that the state and specifically, your ministry, has a duty to intervene in what has become a well-documented failure, where this statutory body has not carried out its stipulated functions due to either, incompetence, poor leadership, arrogance and/or a fundamental evasion of responsibility and fiduciary duties,” he said.

Speaking to GroundUp, Sampson said he personally was owed about R3-million. Payments had become sporadic since about 2017, and after the Covid pandemic, had completely dried up.

“They come up with a multitude of excuses. They claim we didn’t deliver the reports on time. They repeatedly lose invoices. They say the payments are not loaded on their system , and so there must be something wrong but they don’t tell us what’s wrong. They also accuse us of charging above the tariff when they set the tariff.”

Sampson said litigation, for most, was not an option. “We don’t have deep pockets. And because we have not been paid there is nothing rattling in them.

“But we cannot throw away seven years of hard slog. We have nothing left to lose and we just hope the new minister has the zeal and energy to finally deal with the problems at the fund.”

Creecy’s office has acknowledged receipt of the two letters but attempts by GroundUp to get comment from were unsuccessful.

Republished from GroundUp under a Creative Commons Attribution-NoDerivatives 4.0 International License.

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Categories : Emergency Medicine Healthcare Politics and RegulationsTags :

Alarm Raised over Amendments to Road Accident Fund Act

On By ModernMedia
Photo by Pixabay

By Tania Broughton for GroundUp

The Law Society of South Africa (LSSA) has urged members of the public and civic associations to formally object to proposed amendments to the Road Accident Fund Act which, if approved, will have “dire consequences” for all South African road users.

The draft amendment bill was gazetted earlier this month by the transport minister. It proposes major changes to how the fund operates and how it will pay claims.

According to the LSSA, it proposes significant changes to the existing law, including removing the rights of drivers, passengers and pedestrians to claim compensation for injuries they have suffered. Instead, it proposes that the fund will only provide significantly reduced “social benefits”.

And, says the LSSA, an innocent injured party would still be denied the common law claim against the guilty party for the balance of his or her loss.

Yet all road users contribute directly or indirectly to the fund through the fuel levy, estimated to be about R45-billion a year.

“The poor and disempowered, who make up the vast majority of claimants and who are compelled to use public transport, will bear the brunt of the consequences of these amendments. They will be forced into the public health system, as the prescribed tariffs will not cover the actual costs incurred at a private hospital. Under the present system, many receive treatment at dedicated private healthcare facilities,” the LSSA says in its statement.

Claimants will also not receive any lump sum payments and, if they are not able to produce a payslip, it was unlikely that they would receive compensation for loss of earnings.

The LSSA said those who can afford it will be compelled to take out private accident cover for medical and other expenses as well as accident benefits.

“This is likely to be very costly, as there will be no reimbursement of expenses covered from the fund. Medical aids will more than likely exclude cover or the cost thereof will have to materially increase to preserve the funds in the pool for all members.”

The LSSA said road accident victims will be uniquely discriminated against by the proposed legislation.

“Their rights to be compensated for harm suffered by the fault of another will be taken away. Persons who suffer harm from medical negligence or are injured in train or plane or boat accidents or in shopping centres, hotels, construction sites, holiday resorts, private homes or by electrocution or pollution and by a host of other causes, have unfettered rights to seek compensation from the person or entity who caused them harm.

“Innocent motor vehicle accident victims, alone, do not have this right, despite the fact that they pay premiums to the fund.”

At present, injuries sustained in a motor car accident anywhere in South Africa by any person are covered by the Fund.

The Bill now excludes injuries suffered in motor vehicle accidents in parking areas, sports fields, farm roads, driveways, private estates, game reserves or any other private road.

People who are not citizens or permanent residents are also not covered.

Persons crossing a highway are not covered. Persons injured in a hit and run are not covered. Pedestrians, drivers and cyclist who may test over the legal limit for alcohol and their dependents are not covered.

The Bill also proposes doing away with payments for pain and suffering, loss of amenities of life, disability, disfigurement or shock.

It also does away with lump sum payments for loss of earnings or support, replacing them with monthly payments, and giving the fund the right to continually reassess its liability to continue to pay.

While at present all medical and other expenses reasonably incurred that arise directly from the accident are covered, these will now be subject to a prescribed tariff. Any future medical expenses have to be pre-authorised.

The LSSA said the Bill also largely ousts the role of the courts in determining contested claims, establishing instead alternative dispute resolution procedures followed by referral to be a yet-to-be established Road Accident Fund Adjudicator.

Co-chair of the KZN Personal Injury Lawyers Association Anthony De Sousa said the biggest issues around the Bill was what was not known, such as what “social benefits” were and what the treatment tariffs would be.

“We don’t know what we are signing up for”.

“What also worries me is the people it excludes, such as pedestrians crossing highways. They don’t do that for fun. They do it because they have no choice and are trying to get to work or home.

“They are poor people and if they are knocked down, they really need help. To exclude them is just weird.”

He said while there may be a case not to cover motorists who don’t have licences, or who are over the legal alcohol limit, the Bill also proposed that their dependents are not covered, such as a child who is injured.

“The kids are not at fault, but suddenly they have no claim.”

He said the approach seemed to be: “Let’s try and save some money”.

“We pay a lot of money to the fund in terms of the levy. If you were to take that money and take up an insurance policy, you would probably get better cover and better value for money.

“I don’t think, no matter how they change it, it won’t work until they sort out the dysfunctionality, the administrative inefficiencies in the fund. You can change it to whatever system. They cannot properly administer it and run it.

“If they did their jobs properly, the fund would be saving itself a bucket load of money.”

De Sousa said the association was presently putting together its formal response to the proposals.

Collen Msibi, spokesperson for the Department of Transport said, “The bill is out for comments. The department will welcome all views and suggestions for its consideration.”

Comments and objections can be sent to Lindiwe Twala at twala@dot.gov.za or Trevor Mphahlele at mphahlelet@dot.gov.za

The deadline for comments is 8 October.

Republished from GroundUp under a Creative Commons Attribution-NoDerivatives 4.0 International License.

Source: GroundUp

Categories : Injury & Trauma Medical IndustryTags :

Legal Review – Subrogation: Medical Schemes Act on Motor Vehicle Accidents Payments

On By ModernMedia
Photo by Pixabay

John Letsoalo – Senior Manager; Legal Services

Mpho Sehloho – Senior Analyst – Benefits Management

In the ensuing court battle between Discovery Health and the Road Accident Fund (RAF) over reimbursements to be paid on motor vehicle claims, medical schemes members had always sought clarity or a position from the Council for Medical Schemes regarding this. In normative terms, the CMS is not obliged to release commentary on matters remote to its mandate, however, as a responsible regulator, it became a necessary act to clear any anomality.

Medical scheme members usually do not always have the full understating of the arrangements between RAF and medical schemes. At best, members sometimes have difficulty engaging with their scheme’s rules or RAF due to language barrier or be it of a technical nature of the matter.

In terms of the Medical Schemes Act 131 of 1998 (the “MSA”), Medical Schemes undertake liability in return for a contribution by among others granting assistance in defraying expenditure incurred in connection with the rendering of any relevant health services.

MSA further obliges medical schemes to pay for Prescribed Minimum Benefits (PMB), which include any emergency medical condition, under which motor vehicle claims could fall, in full. Unless a claim is specifically excluded in terms of the schemes’ rules and/or does not meet the criteria in terms of the definition of relevant healthcare, the medical scheme must still pay.

Most medical schemes provide for the handling of motor vehicle claims in their rules, wherein members of medical aid can claim compensation from the Road Accident Fund (the “RAF”) for such claims and any future healthcare services which may arise due to such motor vehicle accident. 

It is also common cause that where RAF is responsible for claims, which a medical scheme has paid in terms of its rules and the MSA, that the RAF should refund to such medical scheme the amounts paid. Members of medical schemes who would have claimed directly from the RAF and received compensation for such claims, must also pay such amounts back to the medical scheme. This is commonly known as subrogation.

Should a member not receive any compensation from the RAF even after claiming, the scheme remains liable for the costs of the treatment subject to the registered scheme rules and must not be required to repay/refund such funds to the scheme.

The scheme may, however, attempt to recover such amounts paid from the RAF for the benefit of its members.

Subrogation allows medical schemes to minimise losses as a result of these claims and keep members’ contributions reasonable, by holding responsible parties accountable. It also prevents members from being “overcompensated” or unjustifiably enriched for the loss since they should not receive double compensation from both the medical scheme claim payout and the recovery from the RAF.

It must be emphasized that the financial risk associated with health interventions for which the need is uncertain is equitably shared within the covered population through a risk pool managed by medical schemes under the Medical Schemes Act. Therefore, CMS cannot condone a situation where members of medical schemes are forced to be out of pocket due to the non-payment of medical costs by RAF where these have since been paid out by medical schemes.

In line with our mandate under Section 7 of the Medical Schemes Act, it is not in the members interest if medical schemes are required to claw back payment made on behalf of members due to non-payment of these costs by RAF.

Moreover, the non-recovery of these costs by medical schemes negatively and unfairly withdraws from the entire risk pool that is aimed at benefitting the whole membership.

The World Health Organization (WHO) defines pooling as “…accumulation and management of revenues in such a way as to ensure that the risk of having to pay for healthcare is borne by all members within the pool, not by each contributor individually…” (WHO, 2000).

By implication, the refusal to refund medical schemes by RAF leads to the unfair deterioration of the entire risk pool funds.

Within this background, CMS believes that the refusal to refund medical schemes by RAF is not in line with the provisions of the Medical Schemes Act and it is not in the interest of beneficiaries of medical schemes.

DISCLAIMER: COUNCIL FOR MEDICAL SCHEMES. 2023

This document has been prepared by the author(s) from the Council for Medical Schemes Legal Services Unit and Benefits Management Unit. The views and information expressed in this article are for information purposes only. CMS cannot be held liable for any incorrectness of statements and statistical errors. Recommendations and conclusions are based on the author(s) research outcomes/findings and does not necessarily espouse or state as a CMS policy stance. The information is subject to change without notice. Companies and individuals wishing to use the information must reference the CMS in company reports, news reports, interviews, panel discussions etc.

Categories : Ethics and LawTags :

Road Accident Fund: Experts Withdraw Medical Opinions over Non-payments

On By ModernMedia
Gavel
Photo by Bill Oxford on Unsplash

Medical experts who were under the impression they were contracted by the Road Accident Fund (RAF) to provide expert medical opinions, have written to acting chief justice Raymond Zondo to withdraw their completed opinions that have not yet been used in court because the RAF refuses to pay them or has charged penalties to reduce the amounts owed.

These qualified specialists provided expert medico-legal services, such as consultations and injury assessments, preparation of expert witness reports, attended expert witness meetings, prepared joint minutes of expert meetings, and presented expert evidence in court for the former panel of attorneys rendering this service for the RAF.

The experts say they have had enough of struggling for payments from the RAF and they state in the letter that their work “may not and should not be used as evidence in any matter” in the future because it is said to be unauthorised and not paid for. In effect, this means that RAF cases can no longer progress until these experts have been paid or until new medical expert opinions are obtained.

The RAF only recently informed all medical experts appointed by its former panel of attorneys that they were not authorised to perform these services which were conducted since 2015 and will therefore not be paid.

Mariëtte Minnie, director of MMB Made Easy, which handles medical accounts of medical-legal service providers says accounts she deals with have a total outstanding value of R63.5 million, with some accounts dating back as far as 2015. The biggest outstanding balance among her clients is R10,7 million the RAF owes to one neurosurgeon.

As a result of ongoing non-payment, some experts have shut down and sold their houses and cars due to huge overdrafts and VAT owed to SARS for opinions for which the RAF has not yet paid.

Minnie adds, “The RAF has stolen thousands of medico-legal reports from hundreds of experts which they do not intend to pay for.”

Medical experts have always been instructed by the panel attorneys as RAF representatives, but the RAF never renewed its expert contracts in time. The RAF then terminated the services of the panel of attorneys who had to obtain RAF authorisation for the experts but still asked experts to continue assessing claimants to avoid delays and send their reports directly to the RAF.

Minnie says that invoices for work done in previous years are met with delaying tactics and even denial of payment. “The RAF now implements terms of the service level agreement with the experts to fine them with 5% for every day that their reports are submitted after the due date although submission of reports is subject to factors such as obtaining necessary documentation to finalise the report.”

The RAF has also instituted steps to eradicate “irregular expenditure”, suggesting that experts assessed claimants and wrote reports without authorisation although the RAF failed to implement adequate systems to instruct and remunerate them.

Minnie comments, “The RAF is shambolic and has been unable to operate ethically or effectively since 2015. We will also be bringing this matter to the attention of the Minister of Transport, the Special Investigations Unit, the Public Protector, the National Prosecuting Authority and the National Treasury. New leadership is required to turn around the RAF.”