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Claiming Expenses from Both the Road Accident Fund and Medical Aid: What the Law Says

Claiming Expenses from Both the Road Accident Fund and Medical Aid: What the Law Says
Sep 14, 2021 gnuworld
claiming expenses

After a road accident, it’s common to need expensive medical care. Private hospitals and healthcare practitioners usually demand prompt payment – but a claim against the Road Accident Fund (RAF) can take several years to finalise. So what does the law say about claiming expenses from both the Road Accident Fund and medical aid?

Claiming RAF compensation for costs already covered by medical aid

It is legal to claim compensation for road accident-related medical costs from both your medical aid scheme and the Road Accident Fund (RAF).

However, you’re generally required to refund the medical aid scheme for expenses that are subsequently recovered from the RAF.

If the RAF does not compensate you for particular medical expenses, your medical aid scheme remains liable for those costs, depending on your level of cover and available benefits.

It’s worth noting that a RAF payment may be made up of separate amounts, allocated as compensation for different categories of damages. Examples are medical expenses, loss of income and/or pain and suffering. This will depend on the circumstances surrounding a claim.

As a medical aid member, you’re responsible for paying back only the amount received from the RAF specifically for medical expenses. This applies even if the RAF compensation for medical expenses is less than the amount paid out by your medical aid scheme.

Different approaches by South African medical aids

Medical aid schemes don’t all take a uniform approach to the recovery of accident-related funds from the RAF.

Before settling accident-related claims, some medical aid schemes require members to provide a written undertaking to claim their medical expenses from the RAF and then reimburse the schemes. They put the onus on members to initiate claims on their behalf.

Some medical aid schemes use their own attorneys to claim medical expenses from the RAF. For instance, Libcare contracts the Medical Aid Recovery Unit of Alexander Forbes to process claims submitted to the RAF for reimbursement of funds paid by LibcareMedical Scheme.

As an exception to the rule, at least one scheme – the Government Employees Medical Scheme (GEMS) – has chosen not to lay claim to medical expenses that its members recover from the RAF.

The issue of legal costs when refunding medical expenses

Some medical aid schemes allow their members to deduct legal costs incurred during the RAF claims process from the amount that must be refunded to them.

Other schemes require undertakings from members to repay accident-related medical expenses in full, regardless of legal costs they incur.

Right of medical aids to terminate membership

According to the Medical Schemes Act of 1998, a medical aid scheme has the right to terminate membership if a member fails to repay a debt owing to the scheme.

In 2011, a Council for Medical Schemes ruling upheld this principle in relation to RAF compensation owed to a medical aid scheme.

In R Bobroff & Partners obo Mr M Bellon v. Discovery Health Medical Scheme, the Council found in favour of Discovery Health and a termination of membership was upheld.

How we can help if you have a RAF claim

Pursuing a RAF claim is a lengthy, complex process. For several reasons, it’s not a good idea to submit a RAF claim without professional legal representation.

At DSC Attorneys, we have extensive experience in handling claims against the RAF. Our personal injury attorneys and medico-legal team are committed to helping road accident victims get the compensation they deserve – and we work on a no-win, no-fee basis.

Contact us online or call 0861 465 879 for legal support and representation that’s effective, ethical and caring.

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