Author: Eugene Rossouw – HPCSA Registered Medical Prosthetist
It is an unfortunate reality that we have a high incidence of road traffic accidents on our South African roads. Many of these accidents are associated with devastating injuries and of course, in many unfortunate cases also the death of drivers and passengers.
Serious orthopaedic injuries to the extremities, unfortunately often lead to amputation of a limb, with a significant impact on the function or mobility of the injured individual, affecting activities of daily living as well as the ability to perform occupational tasks.
In the case of limb amputation, the quality of a prosthesis and the prosthetic clinical care can make a significant difference in the rehabilitation of the amputee. High-quality, modern prosthetic technology with the associated rehabilitation practices, can help amputees regain good function and mobility, return to living an active life, and often also enable them to return to work with some adjustments in ergonomics or functional tasks. This can often not be achieved with low-cost, entry-level prosthetic technology. The safety, comfort, reliability, and therefore functional outcome and therefore acceptance of prosthetic limbs, are in most cases directly proportional to the quality of the prosthetic technology.
It is an unfortunate reality that advanced, high-quality prosthetic limb technology comes at a significant cost, not only in the initial provision of a prosthetic limb but also maintenance and replacement thereof. However, should a claim against the Road Accident Fund be successful, the injured individual can have access to a high standard and quality of prosthetic technology at world-class private prosthetic rehabilitation clinics in South Africa. The Road Accident Fund does have reimbursement levels for prosthetic services and technology that allows for this. (It is important to note however that unfavourable apportionments/merits can unfortunately have an impact on an individual’s ability to access high-end prosthetic technology due to apportionment co-payments. Your prosthetic service provider can however in such cases, advise on prosthetic technology that may still offer good function and outcomes, but at a more affordable price level to make co-payments more affordable. As a practical example, should the injured individual have an 80%/20% liability apportionment, the Road Accident Fund will only pay for 80% of the prosthetic costs, and the individual will have a 20% co-payment.)
To access prosthetic fitting and care, the injured individual, with a valid road accident fund undertaking, can have access to prosthetic care at any private prosthetic clinic service provider in their relevant city or area. The majority of reputable prosthetic clinics can be found online and any prosthetic clinic that is registered with the Health Professionals Council of South Africa (HPCSA ) and Board of Health Care Funders (BHF) can be service providers to individuals with valid Road Accident Fund undertakings.
If you are an individual with a valid Road Accident Fund undertaking, you can search for any prosthetic clinic in your area and book a consultation. The prosthetic clinician will then do a physical assessment as well as a functional outcome test (Amputee Mobility Test) and recommend the most appropriate prosthetic technology for your mobility level and functional needs (also considering any apportionment co-payments which may be applicable. In such cases, the prosthetic recommendation could be adjusted, considering the cost implications to the claimant.)
The prosthetic clinic will then draft a proposal and quotation according to a formal format that is submitted directly by the prosthetic clinic to the Road Accident Fund undertakings department. Upon receiving formal pre-authorisation approval from the Road Accident Fund, the prosthetic fitting and associated rehabilitation services can commence. Once the prosthesis is supplied and the delivery and acceptance letter are signed by the amputee, the Road Accident Fund will pay the prosthetic clinic directly.
It is however important to be aware that although the Road Accident Fund does allow for reimbursement of high-end prosthetics, the Fund does in some cases object to recommendations made in pre-authorisation motivations for which a formal appeal may then be needed. However, if the relevant prosthetic clinic is making prosthetic recommendations according to ethical practice guidelines, in most cases the Road Accident Fund will accept appeals, authorise and pay for the appropriate prosthetic technology. The reason for this scrutiny by the Road Accident Fund is that there are in some cases so called ‘’over prescription’’ where prosthetic technology is recommended that is inappropriate for the functional level that can be achieved by the relevant amputee, the Fund then pays for prosthetic technology that cannot fully be utilised by the amputee. The Road Accident Fund is under constant financial pressure and needs to ensure that they are spending funds responsibly.
However, even in cases where the Road Accident Fund rejects the initial proposal and approves a lower-cost prosthesis, this may still be a prosthesis that is of quality and technology far superior to what would be funded by private medical aid or provided by the government/state prosthetic clinics, which typically allows for relatively entry-level prosthetic technology.
Another factor to be aware of is that pre-authorisations can take several months (up to 4 months) to be processed by the Road Accident Fund post-claims department due to administrative pressure and backlogs. However, during this period, the claimant and the prosthetic clinic can be proactive and follow up regularly with the relevant Road Accident Fund claims to handle the department to ensure that pressure is applied for the due processing of such a pre-authorisation. The claimant can also take other proactive steps during this waiting period such as doing various strengthening, mobility, core strengthening, and balance exercises while awaiting approval, which can greatly facilitate the initial stages of prosthetic fitting and mobility once authorisation is received from the Road Accident Fund.
Important final considerations. Choosing the correct legal representation in a claim against the Road Accident Fund is vitally important to ensure that the claim is indeed successful, timeous, and with the appropriate, best possible terms. As detailed in this article, unfavourable merits (liability percentage to the claimant) can make the personal financial contributions to prosthetic technology and services very costly, and in some cases unaffordable to the amputee claimant. Good and experienced legal representation, such as Simpsons Attorneys, is therefore vitally important.
Not only will the appropriate legal representation ensure the best outcome in terms of the claim against the Road Accident Fund, but the professional network between your representative attorney firm and relevant medical service providers is also very valuable. Through legal representation, the amputee claimant can gain access through referral to the most reputable prosthetic clinics that can provide world-class prosthetic care and technology and are experienced in the correct pre-authorisation application process to the Road Accident Fund which is vital in gaining access to the appropriate prosthetic care.
