Over the past year there has been an ongoing social media campaign to highlight that certain medical schemes will not cover its member for injuries sustained as a result of road traffic accidents. It has been said that schemes pressurise members to claim instead from the Road Accident Fund (RAF) for the medical expenses and then settle the scheme for any bills that have already been paid as part of medical aid coverage. However, these claims are largely untrue.

Road Accident Fund Claims or Medical Aid Claims

The issue lies with fraudulent activities being conducted by certain medical aid members. When a medical scheme covers accident-related injuries it has essentially taken funds out of its pool to pay for these bills. Medical aid members are entitled to this cover and schemes will pay it provided that there are no waiting periods or suspensions in place. However, when those same members then approach the Road Accident Fund (RAF) and claim for medical expenses with the intention of pocketing it themselves, then they may face issues with the medical scheme.

As a result of this unethical activity, the medical scheme may then claim the RAF payout for medical expenses from the member themselves. It is only subject to the payments made by the scheme for the member’s bills. This is neither unethical nor fraudulent activity on the part of the medical scheme. They have footed the bill and the member is trying to profit from the RAF by claiming reimbursement for medical expenses. Unfortunately the social media campaign that has done its rounds since early 2014 has not clarified this issue but rather misled consumers at times.

When should medical aid pay and when should RAF pay?

Understanding when your scheme should pay and when the RAF may be held liable needs to be clarified. Your medical scheme is required to cover your accident-related injuries unless it is a non-essential, elective or cosmetic procedure. However, you cannot claim for expenses from the RAF that have already been paid for by your scheme. It may seem logical but some medical aid members believe they can profit from their mishap.

The RAF may still be held liable for other aspects such as loss of income, physical disability and so on which your medical scheme does not cover. Furthermore if your medical scheme does not pay for your accident-related expenses for whatever reason (like an existing waiting period of membership suspension) then an accident victim can claim for medical expenses from the Road Accident Fund (RAF).

It is important to get the facts and not be scared off by dubious claims on social media. Never consider giving up your medical aid cover based on hearsay. Social media is full of myths and misconceptions that can mislead consumers. If you want access to quality private healthcare and do not have the cash resources to pay for it yourself, then medical aid is just about the only reliable way to go. Remember that your scheme may claim for your medical expenses that it paid from the RAF but this money is the scheme’s, not yours.