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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