The High Court in Pretoria has interdicted the Road Accident Fund (RAF) from implementing a directive to reject all claims for past medical expenses where these expenses were paid by medical schemes.
In an internal communiqué dated 12 August, the RAF’s acting chief claims officer instructed regional managers to ensure that their teams assessed claims for past medical expenses and rejected the claims if a medical scheme has already paid them.
“The reason to be provided for the repudiation will be that the claimant has sustained no loss or incurred any expenses relating to the past medical expenses claimed. Therefore, there is no duty on the RAF to reimburse the claimant,” the communiqué said.
Medical schemes administrator Discovery brought an urgent application against the RAF and the Minister of Transport in terms of the Bill of Rights, specifically the provisions of section 38 (“enforcement of rights”) of the Constitution.
Discovery contended that the directive was unlawful and inconsistent with the provisions of section 17 of the RAF Act, which oblige the RAF to pay a claimant’s proven damages, of which past medical expenses are a part.
It said the directive would result in a “significant, unplanned loss of income” for medical schemes, which could lead to an increase in members’ premiums.
Read: Discovery challenges RAF decision to stop paying members’ claims
RAF went ‘rogue and arbitrary’
In a judgment handed down on 26 October, Judge Mandla Mbongwe said the RAF Act does not provide for the exclusion of benefits that a victim of a motor vehicle accident has received from a medical scheme for past medical expenses.
He called the directive a “flagrant disregard” of the provisions of the RAF Act and a “hopeless undermining” of provisions of the Constitution that seek lawfulness, justice and fairness in the exercise of administrative powers.
Judge Mbongwe said Discovery’s urgent application “could not be more justified” and had been “coerced” by the RAF’s directive.
What was more concerning, he said, was that the RAF did not give notice of its intention to introduce the directive and invite comments from stakeholders. “It chose to go rogue and arbitrary.”
RAF must reimburse schemes
Judge Mbongwe said the social security protection the RAF Act provides is “in no way” intended to “impoverish” medical schemes.
He said the fuel levy funds compensation to motor vehicle accident victims, and nothing in the law obliges medical schemes to contribute towards such compensation by the payment of medical expenses without a reasonable expectation of reimbursement upon settlement of the claimants’ claims in terms of the RAF Act.
Judge Mbongwe said medical schemes entered into agreements with their members that they would be reimbursed once their claims were settled.
“Settlements of victims’ claim is in full and final settlement. This means that, unless the past medical expenses form part or are included in the settlement amount, medical aid schemes will not be reimbursed for the medical expenses they paid. Worst still, medical schemes would have no standing to recover those expenses due to the claimants’ claims having been settled in full and final settlement.”
He said the only way for medical schemes to prevent their loss of expenses incurred for the treatment of members injured in vehicle accidents would be to institute concurrent claims against the RAF and in due course seek the consolidation of the hearing of the two matters.
“The costs of the proceedings will be astronomical and unnecessarily incurred by the RAF, which, in terms of the Public Finance Management Act, will constitute wasteful expenditure.”
Judge Mbongwe set aside the directive and interdicted and restrained the RAF from implementing it.
Good afternoon
I f m msomi also not happy about this judgment like im earning disability grant and pay back the 1 who pay for medical aid it actually helps me to pay ptimiums ive injured since 2005 and im not healing and raf payout was 71 thousand its shows that i will leave medical aid to leave with grant
Good day is undertaking is no longer compensate for past medical expenses who belong to medical aid who had an excident at 2005 who had sustained injures from that time til now
Good day
Just asking or coment on behalf of raf stop paying medical expenses do or does raf will pay primuims for medical aid members
Good afternoon
I f m msomi also not happy about this judgment like im earning disability grant and pay back the 1 who pay for medical aid it actually helps me to pay ptimiums ive injured since 2005 and im not healing and raf payout was 71 thousand its shows that i will leave medical aid to leave with grant
Good day is undertaking is no longer compensate for past medical expenses who belong to medical aid who had an excident at 2005 who had sustained injures from that time til now
I am Ramo in 2015 I got involved in an accident and lodge a direct claim with raf on the 03rd November 2015 and in 2017 Septembe 2017 I have signed for interim offer and 100 % statutory undertaking for future medical expenses and my invoices are no longer been paid simply because they were covered by medical aid,I have 8 outstanding invoices they are telling me that their status quo remains they are not going to reimburse me irrespective of what the high court judgement says ,I think raf is bullying us.
I spoke to Dakalo Ndou from Raf sometimes last week and told me that they still awaiting for a formal communication realignment from their head office,today is telling me that I must be advised that the status quo remains my 8 outstanding medical expenses will not be reimbursed since they covered by medical aid,is so frustrating because I pay for that medical and it was not for this accident I would have pay for higher plan I am only paying for high plan because low plan does not cover most of the things such physio and pain management anesthetics,please help. I am paying all the tax duties in the country as well as fuel levy but this is how I am being treated.
Good morning
I was involved in an accident in 2015 March lodge my direct claim on the 03rd November 2015 and in 2017 September I received a call from Raf Johannesburg offices in Marble Tower to come and sign my interim offer as well as 100% statutory undertaking and now I have 8 outstanding invoices that are not paid simply because they were covered by medical aid.On the 19th October the judgement granted declaring the instruction of stopping processing the medical payments unlawful then I spoke to Dakalo Ndou from Raf Jhb offices to honor my invoices and he said to me is still awaiting for formal communication realignment from the head office,today he is telling me that I must be advised that the status quo remains meaning I will not be reimbursed for my medical expenses,it so frustrating simply because I am law abiding citizen paying all tax duties in the country including fuel levy like any other person’s but I am being discriminated,Raf is bullying me is really not fair.