How Does Workmen’s Compensation Work?
The purpose of Workmen’s Compensation is to provide compensation for disablement caused by occupational injuries or diseases sustained or contracted by employees in the course of their employment, or for death resulting from such injuries or diseases; and to provide for matters related to Injuries on Duty.
Here is everything you need to know about Workmen’s Compensation.
- The employee is permitted to freely choose his own service provider e.g. doctor, pharmacy, physiotherapist, hospital, etc. and no interference with this privilege is permitted, as long as it is exercised reasonably and without prejudice to the employee or to the Compensation Fund.
- To avoid disputes regarding the payment for services rendered, medical practitioners should refrain from treating an employee already under treatment by another doctor without consulting / informing the first doctor. As a general rule, changes of doctor are not favoured by the Compensation Fund, unless sufficient reasons exist.
- Pre -authorisation of treatment is not possible and no medical expense will be approved if liability for the claim has not been accepted by the Compensation Fund.
- From 1 January 2004 a certified copy of an employee's identity document will be required in order for a claim to be registered with the Compensation Fund. If a copy of the identity document is not submitted the claim will not be registered but will be returned to the employer for attachment of a certified copy of the employee's identity document.
How are claims processed?
- New claims are registered by the employers and the Compensation Fund and the employer views the claim number allocated online.
- If a claim is accepted as a COIDA claim, reasonable medical expenses will be paid by the Compensation Commissioner.
- If a claim is rejected (repudiated), accounts for services rendered will not be paid by the Compensation Commissioner. The employer and the employee will be informed of this decision and the injured employee will be liable for payment.
- If no decision can be made regarding acceptance of a claim due to inadequate information, the outstanding information will be requested and upon receipt, the claim will again be adjudicated on. Depending on the outcome, the accounts from the service provider will be dealt with as set out in point 2 and 3. Please note that there are claims on which a decision might never be taken due to lack of forthcoming information.
- All service providers should be registered on the Compensation Fund electronic claims system (Umehluko) in order to capture medical reports.
- Medical invoices should be switched to the Compensation Fund using the attached format.
- The status of invoices /claims can be viewed on the Compensation Fund electronic claims system. If invoices are still outstanding after 60 days following submission, the service provider should complete an enquiry form, W.CI 20, and submit it ONCE to the Provincial office /Labour Centre.
- If an invoice has been partially paid with no reason indicated on the remittance advice, an enquiry should be made with the nearest labour centre. The service provider should complete an enquiry form, W.CI 20, and submit it ONCE to the Provincial office /Labour Centre.
- Details of the employee's medical aid and the practice number of the referring practitioner must not be included in the invoice.
- Service providers should not generate multiple invoices for services rendered on the same date i.e. one invoice for medication and a second invoices for other services.
Checklist Of Minimum Requirements
- Name of employee and ID number
- Name of employer and registration number if available
- Compensation Fund claim number
- Service provider’s reference number and invoice number
- The practice number
- VAT registration number
- Date of service
- Item codes according to the officially published tariff guidelines
- Amount claimed per item code and the total of the account
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