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Medical Aid and Injury on Duty Claims for Contractors and Employees
Introduction to IOD Claims
Injuries have the potential to arise from a variety of circumstances whether a fall at home, a motor vehicle accident, assault, or an injury which was sustained in the workplace. Medical aid is something that not all South Africans can afford and there are people who may have to depend on agencies such as the Compensation Commissioner or Workmen’s compensation, or the Road Accident Fund, to ensure that provision can be made for private medical care.
Before further exploring medical aid and injury on duty (IOD) claims for contractors and employees, it is imperative to consider the differences between medical aid, workers’ compensation, and medical aid versus IODs.
Medical Aid versus Workmen’s compensation
There are employees who may be confused regarding the differences that exist between workmen’s compensation and medical aid. These are two completely different forms of cover, where medical aids are privately run organisations which pay for healthcare services to members.
Workers’ Compensation funds are run by government in paying for the medical services which relate to injuries and diseases sustained or contracted in the workplace.
In addition, workmen’s compensation is an essential benefit that employers pay on behalf of their staff whereas medical must be paid by employee. An employer is not legally obliged to provide employees with medical aid subsidies, however, this is something that large organisations offer as an incentive.
Employers who pay for workmen’s compensation, do so if an employee sustains an injury on duty (IOD), to ensure that the employer is not held liable for medical bills relating to the injury. Instead, the Compensation Fund pays for it.
Medical Aid, IODs, and claiming with an IOD
When registering for medical aid, the contract is such that the scheme pays for legitimate, necessary, essential medical services for its member, if there are no waiting period restrictions or other exclusions that apply.
The medical aid makes provision for medical bills up to a certain limit and has a specific tariff guideline. Those who are members of a medical aid scheme who are injured on duty, are likely to have their scheme cover them for the associated healthcare costs.
However, it is imperative that the medical aid scheme be informed of the injury and that it was sustained while on duty. Even though medical costs may be covered by a medical aid, the injured must ensure that their employer submits an injury or accident report to the Compensation Commissioner.
In addition, the workmen’s compensation claim must be completed within the provided time. The medical aid may not cover all services or the limit for the year may have been exceeded in covering for IOD service.
For this reason, the compensation for the IOD claim may be necessary for those who have medical aid covering some of the cost or al of it. It is also crucial to clarify with the medical aid regarding what was paid for medical care and their reimbursement from the Compensation Commissioner.
Careful investigation is necessary into the issue regarding whether the injured person or the medical aid is entitled to reimbursement for expenses that were paid privately. While there may be a degree of difficulty for persons in personally dealing with the Compensation Commissioner’s office, whereas the medical aid could provide necessary advice as to the next step on the matter.
The injured must then ensure that the necessary forms are completed by the employer as well as the medical doctor to facilitate the workmen’s compensation claim.
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Related Content:
Medical-Aid-for-COIDA-WCA-when-claiming-for-injuries-on-duty
See Also:
COIDA /WCA Changes to Assessment Tariffs Categories and Classes 2021
Comments (10)
I lost my finger at work IOD,almost a year ago for the past few months a bone that they left behind has been bothering (hurting) me i've spoken to the doctor and he suggest a another operation... who pays for the operation me or the employer
2024-04-15 21:12:10Hi Donray Under COIDA, if your injury was reported and recognized as an injury on duty (IOD), the costs for medical treatment, including any subsequent operations needed as a result of the initial injury, should be covered by the Compensation Fund, not by you or directly by the employer. It's important to ensure that the further operation recommended by your doctor is pre-approved by the Compensation Commissioner to ensure that the costs are indeed covered.
2024-04-16 07:23:03Hi I injured my back in 2013 and am back at work, however, I am still in pain, every twelve to eighteen months I have to undergo an epidural pain block injection and also have to book alot leave. The doctor who initially saw to me and performed the spine operation has subsequently closed his practice and is no longer practicing medicine. I am trying for the last three years to get this IOD closed. What can I do to speed up the process to get this case closed
2023-05-22 11:45:14Dear Nadiem Thank you for your query via our comments... WCA does not cover pain and suffering. Please share your WCA claim number so that we can check whether the claim was registered and accepted, you can send me your details on basil@safetywallet.co.za If your claim has been registered, you will then need to go to the nearest DOL with all the paperwork to find out if the claim was finalized. Please also take your ID and all relevant medicals with. DOL will also be able to confirm if there is compensation payable to you and what documents they require to do so.
2023-05-24 09:03:06I have my own medical aid and am the owner/member of my company registered with WC. I fractured my heel and was treated by a private medical doctor. I requested the dr to complete the forms WCI4 & 5 and was told after the treatment that his practise does not do IOD and therefore cannot complete either forms and has nothing to do with WC. Is this right and what is it I’m nut getting - I’d like to claim for my salary for which I’ve been off work for over three months?
2023-05-23 20:55:54i was injured but never reach payment methods and they called and said a compony has paid up then they were lost
2023-04-13 19:42:45Hello Percy Thank you for your query via our comments... If you have a claim number you can follow up with WCA...
2023-04-14 07:45:10Last year on May 3th my right hand was cought by a machine at work and I have never gotten a payment
2023-04-14 01:50:54Hello Dumisani Thank you for your comment... You need to follow up with your employer to get your claim number, you must then follow up with WCA...
2023-04-14 07:39:07Hello...my father was working at liebber and services and he was injured on duty 2 days after he dies what decision must I take
2023-11-09 13:06:44Good Day Valentine Thank you for your message via our comments, I am truly sorry to hear about your fathers passing... If the cause of death was due to the IOD, then you need to set up a meeting with the employer and discuss the way forward... The employer must have opened a claim with WCA and also reported the IOD to Department of Employment and Labour as this IOD is regarded as a Sec 24... If all the above has been attended to and WCA have all the medicals and death certificate and have approved the IOD, then WCA will be in contact with you for discussions on the way forward...
2023-11-10 07:55:59Im currently working for a privately owned company.I sustained and injury to my heel in the course of offloading a delivery truck that came in.I then went to a private doctor who suggested for me to get X-rays done,which I did.I thought that everything was sorted and payed for but now,five month later im still getting emails from the hospital requesting payment as the work has not done so.According to my employee they are not liable to pay anything as my injury was a result of "horseplay".Just wanted to know if I take this up to labour law do I have a case
2024-08-07 10:14:23Hi Marico I have replied via email. Thank you for contacting us.
2024-08-08 07:41:25Good afternoon I got injured on duty in 2020.I ended up using my own medical aid.I worked as a cleaner for a school and was employed by the Educational department for 17 years. I received a medical aid and did not contribute towards the medical aid and I was on the lowest option. When I got injured I was taken up in the hospital and needed 3 opparation at different time during my injury. I want to know do I get a refund on my medical aid or was the compansation fund supposed to pay as per IOD thanks
2023-04-23 15:44:09Dear Manuella Thank you for your query via our comments, we really do appreciate it... Your injury on duty should have been reported to WCA and a claim must have been opened... If your school is government state owned, then a different procedure will follow... If your school is private then it will be WCA... May I suggest that you follow up with your school with the progress of your claim...You are welcome to send me an email with more questions if the school is private, but we cannot assist government owned entities...
2023-04-24 09:06:42I am working for a mining company i got injured in 2019 and went operation and the company paid all expenses and this year i had complications with the same injury and i found out the operation was not done properly and as speak i just came back from another operation and i used my medical aid ..why did i use my medical aid for the negligence caused by the Dr and now i might have a permenent disability on top of that i just found out i have cancer and i have to go up and down with treatments and other stuff what if i exhaust all my funds allocated?
2023-10-05 10:33:16Dear Amos I am sorry to hear about your ongoing misfortune regarding your IOD... You need to contact the Compensation Fund that you were registered with in 2019 and find out if they will re-open the claim... If you had complications caused by the DR, maybe you should also report this to Department of Employment and Labour, the severity of your IOD is a Sec 24 and must be reported... You might also want to discuss your concerns with the employer from 2019, maybe they can assist or guide you...
2023-10-06 14:45:35Nice article
2022-11-23 13:15:45Dear Rubini Thank you for your comment, we highly appreciate and value it...
2022-11-24 08:58:13