Special Investigating Units and Special Tribunals Act, 1996
R 385
Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993)Scale of FeesAnnual Increase in Medical Tariffs for Medical Service Providers - 2023Orthotics and Prosthetics Gazette 2023Orthotic and Prosthetic Supply Protocol |
Section 73 Medical expenses
| (1) | The Director-General or the employer individually liable or mutual association concerned, as the case may be, shall for a period of not more than two years from the date of an accident or the commencement of a disease referred to in section 65(1) pay the reasonable cost incurred by or on behalf of an employee in respect of medical aid necessitated by such accident or disease. |
| (2) | If, in the opinion of the Director-General, her medical aid in addition to that referred to in subsection (1) will reduce the disablement from which the employee is suffering, he may pay the cost incurred in respect of such further aid or direct the employer individually liable or the mutual association concerned, as the case may be, to pay it. |
Section 42 Employee to submit to medical examination
| 1. | An employee who claims compensation or to whom compensation has been paid or is payable shall when so required by the Director-General or the employer individually liable or mutual association concerned, as the case may be, after reasonable notice, submit himself at the time and place mentioned in the notice to an examination by the medical practitioner designated by the Director-general or the employer individually liable or mutual association concerned. |
| 1.1 | Each Medical Service Provider should ensure that the service they provides is compatible with the general procurement guidelines issued by National Treasury. |
| 1.2 | The Compensation Fund will bear the reasonable cost for the issue of Orthotic and Prosthetic devices after an accident, provided that liability for the claim has been accepted and the service is prescribed by a medical practitioner and the prescribed guidelines are followed. |
| 1.3 | The published policy on the Supply of Orthotic and Prosthetic devices and the tariff of fees will serve as a guideline to determine if any proposed service is reasonable and it will replace all existing tariff structures. |
| 1.4 | Pre-authorization by the Compensation Fund is required in all claims, even if the devices supplied are listed in the Government Gazette. It is the responsibility of the Medical Service Provider to ensure that liability for the claim by the Compensation Fund and that the service is reasonable and in line with the published policy and tariff. Amputees must be fitted with a prosthesis which is suitable for their environment and activity/load level. |
| 1.5 | Replacement of consumable items, refits and repairs must be motivated by the Medical Service Provider. All requests must be accompanied by photos of the Orthotic/Prosthetic Device to be replaced or repaired. Requests must be reasonable and in line with the published policy and tariff. |
| 1.6 | The employee, assisted by the Medical Service Provider should complete the appropriate form when requesting replacement, re-fit or repair of any Prosthetic/Orthotic device. Refer to Form 6 - Orthotic/Prosthesis Services Request Form. |
| 1.7 | The request for new equipment must be accompanied by a written report by the Medical Service Provider indicating that the employee's functional level has been re-evaluated to take into account any physical or environmental changes encountered by the employee. Refer to AMPPRO Test for Lower Limb amputees. |
| 1.8 | In exceptional circumstances, if the employment status and/or the functional level of an employee radically changes before a new prosthesis is due, a new prosthesis more suitable to the employment conditions will be considered by the Compensation Fund. |
| 1.9 | If an employee's employment status/functional level changes and a prosthesis in a higher category is requested, such higher functional level must be confirmed by the Employer and a rehabilitation team comprising a Medical Doctor, the Prosthetist, a Physiotherapist and/or an Occupational Therapist. |
| 1.10 | The Medical Service Provider must obtain written authorisation for all quotation of Orthotic or Prosthetic devices, refits, consumables and repairs. Accounts will not be payable for any Orthotic or Prosthetic device supplied to the employee without pre-authorisation. |
| 1.11 | The Compensation Fund will bear the reasonable cost of repairs to a prosthesis which has suffered from "fair" wear and tear after at least two years of normal use. |
| 1.12 | The Compensation Fund will not bear the cost of a prosthesis which is lost, broken, worn out or is otherwise unserviceable as a consequence of an employee's neglect or abuse. |
| 1.13 | The Commissioner will pay for the re -fit of the prosthesis strictly only where motivated and justifiable by the circumstances. Refer to Section 4 - Guidelines for Refit. |
| 1.14 | Replacement of some parts of Othotic or Prosthetic devices that may perish or become consumed through, reasonable usage will be paid for by the Compensation Fund in line with the policy guidelines. Refer to Section 3 - Replacement Period Table. |
| 1.15 | The Compensation Fund reserves the right in terms of section 42 of the act to call for a second or independent opinion or evaluation of proposed Orthotic/Prosthetic services. |
| 1.16 | Any such report obtained by the Compensation Fund shall state whether the proposed Orthotic/Prosthetic service is appropriate for the diagnosis, functional level and environmental circumstances of the patient. The Compensation Fund reserves the right to use the information so obtained at his discretion and as is deemed appropriate. |
| 1.17 | The Commissioner is further entitled, pursuant to a complaint by the employee, to call for an independent report concerning any Orthotic/Prosthetic services that have been rendered. The Medical Service Provider should strive to take all reasonable steps to attend to the legitimate complaints of an employee regarding services or assistive devices supplied. If it is found that defective or unsuitable devices have been supplied to an employee the Medical Service Provider shall replace/repair/alter such devices at no additional cost to the Compensation Fund or the employee. The Compensation Fund reserves the right to decide on whether to maintain the said service provider on their data base of service providers or not. |
| 1.18 | The Orthotic and/or Prosthetic devices paid for by the Compensation Fund remains the property of the Compensation Fund. When an employee demises such devices should be returned to the Compensation Fund. |
| 1.19 | Each request for Pre-authorisation should be accompanied by a quotation on the Medical Service Provider's practice letterhead. |
| 1.20 | Every Medical Service Provider should supply the Compensation Fund with the rehabilitation report for all new amputees after fitting and supplying of a new prosthesis. |
| 1.21 | Medical Service Providers are required to quote a similar or better component using the same code. |
| 1.22 | The Compensation Fund retains the right to verify all products supplied to the employee. |
| 1.23 | Acknowledgement of receipt of Orthotic/Prosthetic device should be signed by the Medical Service Provider, Injured Employee and Compensation Fund official (Form 8). |
| 1.24 | In order for the Compensation Fund to verify that the correct items were supplied, proof of purchase should accompany the acknowledgement of receipt for any single component/item in excess of R50 000. |
| 2. | Request for Orthotic/Prosthetic Services |
The following details must accompany the request for prosthetic services:
| 2.1 | Orthotic/Prosthetic Service Request Form (Form 6) |
| 2.2 | Motivation for services by Medical Service Provider |
| 2.3 | Doctor's Referral letter for any Primary Orthotic/Prosthetic device user |
| 2.4 | AMPRO test (for Lower Limb Prosthesis only) |
| 2.5 | Refit report (for refit of prosthesis only) |
| 2.6 | Quotation according to published tariffs (Form 7) |
| 2.7 | Photos of Orthotic/Prosthetic device to be replaced/repaired |
| 3. | Replacement Periods of Medical Orthotic/Prosthetic Equipment |
|
3.1 |
Prosthesis |
Five years |
|
3.2 |
Refit for prosthesis |
Two and a half years |
|
3.3 |
Additional refit socket for Primary amputees initial |
Within the first 12 months after |
|
3.4 |
Silicon liners, gel liners, suspension sleeves |
Two per year |
|
3.5 |
Prosthetic socks |
Twelve per year |
|
3.6 |
If worn with silicone or gel liners |
Six per year |
|
3.7 |
Prosthetic sheath |
Twelve per year |
|
3.8 |
If worn with silicone or gel liners |
Six per year |
|
3.9 |
Cosmetic stockings |
Three pairs per year |
|
3.10 |
Cosmetic cover |
One per year |
|
3.11 |
Calipers |
Every Two years |
|
3.12 |
Manual Wheelchairs |
Every Three years |
|
3.13 |
Motorized Wheelchairs |
Every Five years |
|
3.14 |
Major Repairs to Motorized Wheelchairs |
Every Two and a half years |
|
3.15 |
Wheelchair cushions (specialized) |
One per year |
|
3.16 |
Wheelchair cushions (foam) |
One per year |
|
3.17 |
Wheelchair cushions covers |
Two per year |
|
3.18 |
Orthopaedic footwear |
Two pairs per year |
|
3.19 |
Footwear modifications |
Three modifications per year |
|
3.20 |
Compression stockings |
Four pairs every year |
|
3.21 |
Off the shelf orthosis |
Two per year |
|
3.22 |
Custom made orthosis |
Two every year |
| 4. | Guidelines for Refit |
This guideline covers Prosthetic devices that require refit of the socket after the initial issue. A full motivation with a report indicating the following details must be submitted:
| 4.1 | Date of amputation |
| 4.2 | Date when the present prosthesis was fitted |
| 4.3 | Description of the prosthesis |
| 4.4 | Residual limb measurements when prosthesis was fitted |
| 4.5 | Symptoms indicating loss of fit |
| 4.6 | Diagnosis of loss of fit |
| 4.7 | Current residual limb measurements. |
| 4.8 | Number and thickness of prosthetic socks and worn by employee |
| 4.9 | Condition of prosthesis |
| 4.10 | The employee's current activity level |
| 4 .11 | An opinion as to the suitability of the specific prosthesis for the employee |
| 4.12 | Photos of the prosthetic device to be refit/repaired |
| 5. | Functional Level |
A determination of the medical necessity for certain components/additions to a prosthesis is based on the potential functional ability of the employee. Potential functional ability is defined as the reasonable expectation of the rehabilitation team including a Medical Doctor, the Prosthetist, a Physiotherapist and/or an Occupational therapist and the employee based on
| • | past history including prosthetic use |
| • | current condition including the status of the residual limb and other medical factors |
| • | employment status |
| • | desire to ambulate |
The clinical assessment for Lower Limb amputees should be based on the AMPPRO test results.
