Medical Aid/Insurance and Compensation

What does the law say about Medical Aid / Insurance and Compensation in the workplace in South Africa, including medical aid funds, hospital bills, medical insurance claim etc.
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What type of health care systems operate in South Africa?

There are two kinds of health care systems in South Africa: private and public.

The private system is expensive, and caters to a smallish percentage of the population. It is run on commercial lines and is mainly used by middle- and high-income earners who generally belong to a medical scheme.

The public system is used by most of the population, and is a much cheaper option. However, the public system faces many challenges such as understaffing and lack of medical equipment.

What kind of health insurance or medical aid schemes exist in South Africa?

There are several private health insurance, or medical aid schemes. As a policy holder you pay a monthly fee to the medical aid or insurance company, which allows you to be medically covered up to a certain amount. The schemes vary, depending on how much you pay in – some only cover hospital fees, while others cover everything from visits to the doctor to chronic medicines.

Currently, there is no public national health insurance system in South Africa. But the government and associated partners are working on establishing such a system, in order to benefit those who are too poor to afford decent health care coverage. NHI (National Health Insurance) is aimed at improving service provision and health care delivery, especially to more vulnerable members of the population.

Do employers contribute to private medical aid schemes?

Yes. Some employers contribute a percent of the total contribution the employee makes.

Is there a difference between medical aid schemes and health insurance?

Yes. Medical aid schemes are governed by the Council for Medical Schemes. Health insurance is governed by the Long Term and/or Short Term Insurance Act. The two systems pay out differently, and cover costs differently. It is important to compare systems to see what they offer, before buying into a policy or scheme.

How are workers covered if they get sick or injured?

Workers who are injured or contract a disease through their work are able to claim money from the Compensation Fund. Families can also claim if their breadwinner died through work-related disease or injury.

What type of injuries or diseases are covered?

Occupational diseases (diseases caused by exposure to conditions or substances at the workplace) and workplace injuries (sustained at work).

Who is covered by the Compensation Fund?

Workers who:

  • Are hurt in an accident while busy with their work.
  • Have contracted a disease through their work.
  • Have died from a workplace accident or occupational disease.

What kind of work or contract must a worker have to qualify for the Compensation Fund?

  • Working (permanent or casual).
  • Training.
  • Completing an apprenticeship.

Do workers contribute to the Compensation Fund?

No. Employers pay into the Compensation Fund once a month. Employers cannot deduct money from workers' wages as contributions to the fund.

What does the Compensation Fund cover?

All the worker’s medical expenses must be paid for up to two years from the date of the accident or the diagnosis of the disease. All medical accounts should be submitted to the Compensations Commissioner. This includes fees for transporting an injured employee to a hospital or to their home.

How do you claim?

The injured party must tell their employer as soon as possible after the injury or diagnosis of disease. The employer must report a workplace injury within seven days. They must report an occupational disease within 14 days of finding out. They must report either of these to the Compensation Commissioner. A doctor’s report is also required. The worker does not have to pay for the doctor’s examination. The employer must check that all the relevant forms have been completed, and that copies are kept by both employer and employee.

Who pays?

The worker gets compensation from the Compensation Fund and not directly from his/her employer. This means that the employer does not have to worry about expensive claims.

What if my company is covered by an insurance fund?

Some companies insure their workers with a private insurance fund. In this case, claims are still made to and decided by the Compensation Commissioner. But the payouts are made by the insurance fund of the employer (not by the Compensation Fund). Some of them pay better benefits.

What if a worker dies on the job?

Compensation can be claimed by the widow or dependants of a worker who dies as a result of a work-related accident or disease. The Compensation Fund will pay out varying amounts.

Read more

Find out more about Health and Safety in South African workplaces.


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