CONTENTS
4
SECTION 1: OVERVIEW
6
What is COID and COIDA?
6
About RMA
7
What does RMA do?
8
Who are the employers covered by RMA?
9
SECTION 2: DEFINITIONS
12
What is an occupational accident?
12
What is an occupational disease?
12
Who is an employer?
19
Who is an employee?
20
WHO IS A DEPENDANT?
20
WHO IS A HEALTHCARE PROVIDER?
21
WHAT ARE MEDICAL EXPENSES?
21
SECTION 3: RETURN OF EARNINGS SUBMISSIONS AND
premium PAYMENT TO RMA
22
Submitting ROEs and making payment to RMA
23
Registering with RMA’s Online Services
24
SECTION 4: REPORTING AN accident AND SUBMITTING A
CLAIM TO RMA
26
1. What is my responsibility when my employee has a
work-related accident?
26
2. WHEN SHOULD I REPORT AN INJURY OR DISEASE?
27
3. WHAT DO I NEED TO REPORT TO RMA?
29
4. WHAT IF I DELAY REPORTING THE INJURY OR DISEASE TO RMA?
29
Rand Mutual Assurance Employer Manual 2016/17
5. HOW DO I REPORT AN Accident TO RMA?
30
6. HOW DO I SUBMIT A CLAIM TO RMA?
30
7. HOW DO I REPORT AN ACCIDENT TELEPHONICALLY TO RMA?
32
8. WHAT INFORMATION AND DOCUMENTATION DO I NEED TO
SUBMIT WITH MY CLAIM?
9. UNDERSTANDING YOUR CLAIM NUMBER
10. HOW TO CLAIM FOR A MULTI-PERSON EVENT
33
34
35
11. WHAT IS REQUIRED FOR RMA TO ACCEPT LIABILITY?
35
12. UNDERSTANDING WHEN TO SUBMIT MEDICAL REPORTS
35
13. HOW DO I HANDLE A NOISE INDUCED HEARING LOSS (NIHL)
CLAIM?
14. How do I claim for an employee working abroad?
36
SECTION 5: COID BENEFITS
37
39
1. TEMPORARY TOTAL DISABLEMENT
39
2. PERMANENT DISABLEMENT
44
3. DEATH BENEFITS
48
4. What are the COID benefits for 2016/17?
51
5. MEDICAL EXPENSES
53
SECTION 6: REVIEWS/APPEALS
57
SECTION 7: TRAINING
58
1. ONLINE SYSTEM TRAINING
58
2. LIVE WEBINARS
59
SECTION 8: FRAUD
60
SECTION 9: CONTACT US
62
RMA Branches
62
Rand Mutual Assurance Employer Manual 2016/17
5
SECTION 1: OVERVIEW
What is COID and COIDA?
The Compensation for Occupational Injuries and Diseases Act (COIDA), 130 of 1993 as
amended, provides for compensation to employees who are injured at work, contract
an occupational disease or who die as a result of their occupational injuries or diseases.
COIDA permits the Minister of Labour to licence a mutual association to provide COID
benefits to certain industry classes. Rand Mutual Assurance (RMA) is such a mutual
association licenced to provide COID benefits.
COIDA came into effect on 1 March 1994, replacing the Workman’s Compensation Act
(WCA) of 1941, and has a wider scope than the previous WCA.
COIDA regulates how and when employees who have been injured at work or who
have contracted an illness or disease in the workplace are compensated and clearly
sets out the legal requirements for tariffs, compensation and the limitations for
workers’ claims.
COID benefits provide for medical examination and treatment, disability certification
and compensation. Similarly, when an employee has died as a result of injuries
sustained in the workplace or an occupational disease, the dependents of the
deceased employee may qualify for benefits.
6
Rand Mutual Assurance Employer Manual 2016/17
ABOUT RMA
Rand Mutual Assurance (RMA) is a mutual assurance company with a track record
of more than 120 years in the administration of claims for occupational injuries and
diseases according to the Compensation for Occupational Injuries and Diseases Act
(COIDA), 130 of 1993, as amended.
RMA is passionate about caring for the lives of its claimants and their families. It
embodies its slogan of Caring, Compassionate Compensation at every level of the
organisation, from its empathetic staff to embracing good corporate citizenship.
RMA’s value lies not only in its compassionate approach, but in the excellent systems
and processes it has in place to ensure timeous and efficient payment of valid claims.
RMA has the licence to administer the claims for both Class IV (mining) and Class XIII
(iron, steel, artificial limbs, galvanising, garages, metals and related industries).
Through its market-leading IT system, RMA offers enhanced efficiencies for the
administration and paperless adjudication of COID claims. As a company that is
compassionate and caring, RMA goes the extra mile to ensure that beneficiaries and
their families receive the care and compensation they are entitled to when they have
sustained either a work-related injury or occupational disease.
Founded on 1 June 1894, RMA is a non-profit mutual assurance company which is
owned by its policy holders. RMA operates in terms of section 30 of COIDA, under
licence from the Minister of Labour. The RMA Group also operates under both shortand long-term insurance licences issued by the Financial Services Board (FSB).
With its head office in Johannesburg and regional walk-in branches located in
Carletonville, Durban, eMalahleni, Johannesburg, Klerksdorp, Pretoria, Rustenburg
and Welkom, RMA has a wide footprint and is easily accessible to its clients, claimants
and other stakeholders. In addition, RMA has satellite offices in Lesotho, Mthatha and
Mozambique.
An active training department has an all-encompassing approach to ensuring that
stakeholders have a sound knowledge of RMA’s products and processes and how to
access the online service facilities.
Rand Mutual Assurance Employer Manual 2016/17
7
WHAT DOES RMA DO?
The core of RMA’s business is the receipt, adjudication and administration of workers’
compensation claims, including the payment of medical costs, once-off disability
payments and the ongoing payment of pensions in the case of severe disability and
death.
The Compensation Fund is responsible for overseeing the compliance of RMA
regarding all the requirements of COIDA.
In addition to COID, RMA identified a need for a range of value added non-COID
products to service its clients. These products, which are currently offered to mining
industry clients through RMA Life Assurance Company Limited, include:
•
•
•
•
•
•
8
Commuting Journey Policy (CJP)
Augmentation Policy
Riot & Strike Policy
Stated Benefit (Funeral) Policy
Maternity Income Protection Plan
Group Personal Accident (GPA)
Rand
Rand Mutual
Mutual Assurance
Assurance Employer
Employer Manual
Manual 2016/17
2016/17
WHO ARE THE EMPLOYERS COVERED BY RMA?
RMA has the licence to administer the claims for both Class IV (mining) and Class XIII
(iron, steel, artificial limbs, galvanising, garages, metals and related industries).
Class IV
These employers belong to the mining and mining related industries and have the
option to be administered by either RMA or the Compensation Fund. Premiums are
paid to the chosen insurer and claims can only be submitted to that insurer.
Subclasses within Class IV include:
Subclass
Description
0400
Underground mining and/or prospecting for any kind of mineral,
metal and precious or semi-precious stones where such activities are
conducted by means of shafts, tunnels and winches, but excluding
coal mining; mine dump contracting.
0411
Coal mining
0420
Open cast mining, including slate quarrying but excluding coal mining
and quarrying elsewhere rated; recovery of diamonds from sea, alluvial mining and/or surface workings in connection with the recovery of or prospecting for any kind of mineral, metal and precious or
semi-precious stones; working of sand, gravel and clay pits; recovery
of gold from mine dumps; working of salt pans
0440
Quarrying of stone, flint, lime, etc. including stone crushing and all
other operations incidental thereto
0441
Stone crushing operations as a separate business
Class XIII
These employers belong to the iron, steel, artificial limbs, galvanising, garages, metals
and related industries. Effective from 1 March 2015, it is mandatory for all employers
within this class to belong to RMA as per the Government Gazette Notice 565 of 2014.
All premiums must be paid to, and claims submitted to, RMA from this date.
Rand Mutual Assurance Employer Manual 2016/17
9
Subclasses within Class XIII include:
10
Subclass
Description
1300
Iron and steel production including processing and all quarrying and/
or mining as well as other operations if incidental thereto.
1301
Foundry products manufacturing as a separate business; stove
manufacturing.
1331
Iron button, buckle, hook, eye, hairpin and/or metal badges and
brooch manufacturing; air-gun pellet manufacturing; leaden toy
and novelty manufacturing; solder manufacturing; Venetian blind
manufacturing and repairing; artificial limb manufacturing and
repairing; manufacturing of vehicle and other, number plates.
1340
Metal tube manufacturing; metal furniture, door and/or window
manufacturing; sheet metal products manufacturing as a separate
business; wire, wire spring, wire rope, wire goods, fencing and/or gate
manufacturing; tin container manufacturing; lead pipe manufacturing;
blacksmith as a separate business (including farriers); iron bedstead
manufacturing, cutlery manufacturing including repairing if
undertaken by the manufacturer; scale making and repairing; cycle
frame manufacturing; electro-static powder spray painting; metal
spraying; derusting of metals; manufacturing of gas products, electric
battery; accumulator and/or electrode manufacturing; building
and/or repairing of ships (other than fibreglass, wooden or sailing
ships) including repairs to ships whilst moored to the quay side or
anchored in the harbour or roadstead or whilst undergoing trial runs;
chain manufacturing as a separate business; aluminum products
manufacturing and installation; welding as a separate business;
galvanizing as a separate business; metal products manufacturing
including the business of saw doctors; lighthouse and/or marine
lighting engineering and metal or engineering works not otherwise
classified but excluding structural steel erection or steel reinforcing
operations rated under subclasses 0530 or 0532.
Rand Mutual Assurance Employer Manual 2016/17
Subclass
Description
1350
Electric cable manufacturing; manufacture of safety razor blades.
1360
Motor car assembly as a business including all operations in
connection therewith.
1361
Motor garaging, including servicing and/or repairing of motor
vehicles; the business of the owner of a motor graveyard or scrap yard;
the business of an automotive electrician as a separate business; petrol
and oil filling station; locksmithing; aircraft repairing and/or servicing
as a separate business; employment of parking attendants; the
business of a dealer in new/second hand motor vehicles; motor vehicle
hiring if repairs are undertaken.
Note:
(a)The sale of motor spare parts and/or cars etc., as well as the supply
of petrol, oil and/or air is incidental to the business of a motor
garage owner whether such services are supplied on the garage
premises or not.
(b)This rate also applies to a dealer in second-hand spare parts if the
employer undertakes the dismantling of cars.
1363
Wagon, coach, carriage and/or motor body building as a separate
business; panel beating and spraying as a separate business; motor car
radiator manufacturing and repairing as a separate business
Rand Mutual Assurance Employer Manual 2016/17
11
SECTION 2: DEFINITIONS
WHAT IS AN OCCUPATIONAL ACCIDENT?
COIDA defines an occupational accident as one that arises out of and in the course
of an employee’s employment and results in personal injury, illness or death of the
employee. This means that an employee can claim for benefits if they are injured in an
accident while they doing their work.
WHAT IS AN OCCUPATIONAL DISEASE?
Occupational diseases are illnesses that are caused by substances or agents that the
employee is exposed to in the workplace. It may take some time for a disease to
manifest.
Schedule 3 of COIDA sets out the occupational diseases that arise as a result of
exposure to these agents. An employee can claim compensation if they develop
occupational diseases as a result of these agents.
12
Rand
Rand Mutual
Mutual Assurance
Assurance Employer
Employer Manual
Manual 2016/17
2016/17
Diseases covered in Schedule 3 of COIDA
1. Occupational diseases caused by exposure arising from work activities
caused by:
1.1 Chemical agents
Beryllium or its compounds; cadmium or its compounds;
phosphorus or its compounds; chromium or its
compounds; manganese or its compounds; arsenic
or its compounds; mercury or its compounds; lead
or its compounds; fluorine or its compounds; carbon
disulphide; halogen derivatives of aliphatic or aromatic
hydrocarbons; benzene or its homologues; nitro-and
amino-derivatives of benzene or its homologues;
nitroglycerine or other nitric acid esters; alcohols,
glycols or ketones; asphyxiants like carbon monoxide,
hydrogen sulfide, hydrogen cyanide or its derivates;
acrylonitrile; oxides of nitrogen; vanadium or its
compound; antimony or its compound; hexane;
mineral acid; pharmaceutical agents; nickel or its
compounds; thallium or its compounds; osmium or
its compounds; selenium or its compounds; copper or
its compounds; platinum or its compounds; tin or its
compounds; zinc or its compounds; phosgene; corneal
irritants like benzoquinone; ammonia; Isocyanates;
pesticides; sulphur oxides; organic solvents; latex or
latex-containing products; chlorine; and other chemical
agents at work not mentioned in the preceding
items where a direct link is established scientifically,
or determined by methods appropriate to national
conditions and practice, between the exposure to these
chemical agents arising from work activities and the
disease(s) contracted by the worker.
Rand Mutual Assurance Employer Manual 2016/17
13
Diseases covered in Schedule 3 of COIDA (Continued)
1.2 Diseases caused by 1.2.1 Hearing impairment caused by noise
physical agents:
1.2.2 Diseases caused by vibration (vibration of muscles,
tendons, bones, joints, peripheral blood vessels or
peripherals nerves)
1.2.3 Diseases caused by compressed or decompressed
air
1.2.4 Diseases caused by ionizing radiations
1.2.5 Diseases caused by optical (ultraviolet, visible light,
infrared) radiations including laser
1.2.6 Diseases caused by exposure to extreme
temperatures
1.2.7 Diseases caused by other physical agents at work
not mentioned in the preceding items where a
direct link is established scientifically, or determined
by methods appropriate to national conditions
and practice, between the exposure to these
physical agents arising from work activities and the
disease(s) contracted by the worker.
1.3 Biological agents
and infectious or
parasitic diseases:
1.3.1 Brucellosis
1.3.2 Hepatitis viruses
1.3.3 Human immunodeficiency virus (HIV)
1.3.4 Tetanus
1.3.5 Tuberculosis
1.3.6 Toxic or inflammatory syndromes associated with
bacterial or fungal contaminants
1.3.7 Anthrax
1.3.8 Leptospirosis
14
Rand Mutual Assurance Employer Manual 2016/17
Diseases covered in Schedule 3 of COIDA (Continued)
2. Occupational diseases by target organ system
2.1. Respiratory
diseases
2.1.1 Pneumoconioses caused by fibrogenic mineral dust
(silicosis, anthraco-silicosis, asbestosis).
2.1.2 Silicotuberclulosis Pneumoconiosis caused by nonfibrogenic dust.
2.1.3 Siderosis
2.1.4 Bronchopulmonary diseases caused by hard-metal
dust.
2.1.5 Bronchopulmonary diseases caused by dust of
cotton (byssinosis), flax, hemp, sisal or sugar cane
(bagassosos).
2.1.6 Asthma caused by recognised sensitising agents or
irritants to the work process.
2.1.7 Extrinsic allergic alveolitis caused by the inhalation
of organic dusts or microbially contaminated
aerosols arising from work activities.
2.1.8 Chronic obstructive pulmonary diseases caused by
inhalation of coal dust, dust from stone quarries,
woods dust, dust from cereals and agricultural
work, dust in animal stables, dust from textiles, and
paper dust, arising from work activities.
2.1.9 Diseases of the lung caused by aluminum.
2.1.10 Upper airway disorders caused by recognised
sensitising agents or irritants inherent to the work
process.
Rand Mutual Assurance Employer Manual 2016/17
15
Diseases covered in Schedule 3 of COIDA (Continued)
2.1.11 Other respiratory diseases not mentioned in the
preceding items where a direct link established
scientifically, or determined by methods
appropriate to national conditions and practice,
between the exposure to risk factors arising from
work activities and the disease(s) contracted by
the worker.
2.2 Skin diseases
2.2.1 Allergic contact dermatoses and contact urticaria
caused by the other recognised allergy-provoking
agents from work activities not included in other
items.
2.2.2 Irritant contact dermatoses caused by other
recognised irritant agents arising from work
activities not included in other items.
2.2.3 Vitiligo caused by other recognised agents arising
from work activities not activities.
2.2.4 Other skin diseases caused by physical, chemical or
biological agents at work not included under other
items where a direct link is established scientifically,
or determined by methods appropriate to national
conditions and practice, between the exposure
to risk factors arising from activities and the skin
disease(s) contracted by the worker.
2.3 Musculoskeletal
disorders
2.3.1 Radial styloid tenosynovitis due to repetitive
movements, forceful exertions and extreme
postures of the wrist.
2.3.2 Chronic tenosynovitis of hand and wrist due to
repetitive movements, forceful exertions and
extreme postures of the wrist.
2.3.3 Olecranon bursitis due to prolonged pressure of
the elbow region.
16
Rand Mutual Assurance Employer Manual 2016/17
Diseases covered in Schedule 3 of COIDA (Continued)
2.3.4 Prepatellar bursitis due to prolonged stay in
kneeling position.
2.3.5 Epicondylitis due to repetitive forceful work.
2.3.6 Meniscus lesions following extended periods of
work in a kneeling or squatting position.
2.3.7 Carpal tunnel syndrome due to extended periods
of repetitive forceful work, work involving vibration,
extreme posture of the wrist, or a combination of
three.
2.3.8 Other musculoskeletal disorders not mentioned
in the preceding items where a direct link is
established scientifically, or determined by methods
appropriate to national conditions and practice,
between the exposure to risk factors arising from
work activities and the musculoskeletal disorder(s)
contracted by the worker.
2.4 Mental and
behavioural disorders
2.4.1 Post-traumatic stress disorder
2.4.2 Other mental or behavioural disorders not
mentioned in the preceding item where a direct
link is established scientifically, or determined by
methods appropriate to national conditions and
practice, between the exposure to risk factors
arising form work activities and the mental
behavioural disorder(s) contracted by the worker.
Rand Mutual Assurance Employer Manual 2016/17
17
Diseases covered in Schedule 3 of COIDA (Continued)
3. Occupational Cancer
4. Other diseases
Cancer caused by the following agents:
Asbestos; benzidine and its salts; bis-chloromethyl ether
(BCME); chromium VI compounds; coal tars, coal tar
pitches or soots; beta-naphthy lamine; vinyl chloride;
benzene; toxic nitro and amino-derivatives of benzene or its homologues; lionising radiations; tar pitch,
bitumen, mineral oil, anthracene, or the compounds,
products or residues of these substances; Coke oven
emissions; nickel compounds; wood dust; arsenic and
its compounds; beryllium and its compounds; cadmium
and its compounds; erionite; ethylene oxide; hepatitis
B virus (HBV) and hepatitis C virus (HCV); and cancers
caused by other agents at work not mentioned in the
preceding items where a direct link established scientifically, or determined by methods appropriate to national
conditions and practice between the exposure to these
agents arising from work activities and the cancer(s)
contracted by the worker.
4.1 Miners’ nystagmus
4.2 Other specific diseases caused by occupations or
processes not mentioned in this list where a direct
link is established scientifically, or determined by
methods appropriate to national conditions and
practice, between the exposure arising from work
activities and the diseases(s) contracted by the
worker.
(In the application of this list the degree and type of exposure and the work or occupation
involving a particular risk of exposure should be taken into account when appropriate)
18
Rand Mutual Assurance Employer Manual 2016/17
WHO IS AN EMPLOYER?
An employer is anybody who employs an employee and includes any person
controlling the business of an employer.
The employer pays premiums to RMA based on the earnings paid to employees. The
employer may not deduct any money from an employee’s salary or wages towards
these contributions.
Rand Mutual Assurance Employer Manual 2016/17
2016/17
19
WHO IS AN EMPLOYEE?
Any person who is employed and works under a contract of service or is being trained
as an apprentice by an employer, including learnerships. Casual employees, directors
and labour broker employees are considered employees whilst they are employed for
the purpose of the employer’s business.
Exceptions:
• Domestic workers employed in private households;
• Members of the South African National Defence Force and South African Police Services;
• Employees who live outside of South Africa for more than 12 months at a time, unless there is a special agreement with RMA.
The above are not considered employees by COIDA and therefore cannot claim COID benefits.
WHO IS A DEPENDANT?
According to section 1 of COIDA, a dependant of an employee can be any one the
following:
• A widow/widower who at the employee’s death was married to the employee
according to civil law (provided the marriage is registered with the relevant
Ministry of Home Affairs and a marriage certificate can be produced);
• A widow/widower who at the time of the employee’s death was married to the
employee according to indigenous law or custom, so long as neither the husband
nor wife also had an existing marriage under civil law;
• If there is no widow/widower, a person with whom the employee was living with
as husband and wife at the time of the employee’s death;
• A child under the age of 18 of either the employee or his/her spouse. This
includes posthumous children, step-children, adopted children and children born
out of wedlock;
• A child over the age of 18 of either the employee or his/her spouse, and a parent
or any person who is acting in the place of a parent, a brother, sister, half-brother,
20
Rand Mutual Assurance Employer Manual 2016/17
half-sister, grandparent or a grandchild of the employee; and
• A parent of the employee or any person who is acting in the place of a parent,
and who at the time of the employee’s death was wholly or partially dependent
on the employee.
WHO IS A HEALTHCARE PROVIDER?
A healthcare provider refers to anyone rendering medical care, including doctors,
specialists, allied health professionals (physiotherapists, chiropractors, dieticians,
biokineticists, occupational therapists etc.), psychologists, psychiatrists and others.
WHAT ARE MEDICAL EXPENSES?
Medical expenses are payable to medical service providers for treatment of the
occupational injuries or diseases, subject to COIDA limits. (Please refer to page 53 for
more information).
Rand Mutual Assurance Employer Manual 2016/17
2016/17
21
SECTION 3: RETURN OF
EARNINGS SUBMISSIONS AND
PREMIUM PAYMENT TO RMA
Employers must submit their return of earnings (ROEs) to RMA by 31 March each year.
The penalties for non-submission are in terms of section 83(6)(b) of COIDA.
On receipt of your ROEs, RMA will auto generate an invoice for premium payment.
Section 86(1) of COIDA prescribes that an invoice is payable within 30 days after
the date of the notice of assessment (30 days of the invoice date) or in agreed to
instalments at times and on conditions as determined.
Once payment has been received and cleared, RMA will generate a Letter of Good
Standing for your company.
22
Rand
Rand Mutual
Mutual Assurance
Assurance Employer
Employer Manual
Manual 2016/17
2016/17
Please follow the below process to submit your earnings to RMA.
1. Online declarations
You may complete an online declaration via our website by following the below steps
(please note that you need to be registered with RMA’s online services in order to be
able to submit earnings online):
Step 1:
Step 2:
Step 3:
Step 4:
Step 5:
Visit the RMA website at: www.randmutual.co.za.
Click on the orange Online Services tab.
Click on the Earnings Declaration Submission link.
Click on the Online Declarations link, followed by “New Declaration”.
Upload the authentication key into the “Authentication file” field in order to submit the declarations.
Once you have submitted your online declarations you may download your invoice
online as follows:
Step 6: Click on the Invoice tab, followed by “My Invoice”.
2. Manual declarations:
If you are unable to submit your declarations online, you may submit as follows:
Step 1: Step 2:
Step 3:
Step 4:
Step 5:
Visit the RMA website at www.randmutual.co.za
Click on the Downloads tab
Click on the Employer – Employer Forms link
Download the Earnings Declaration Form
Email the completed and signed form to
[email protected]
3. VAT number
RMA requires your company VAT number which can be emailed to us on
[email protected].
Rand Mutual Assurance Employer Manual 2016/17
23
HOW DO I REGISTER WITH RMA’S ONLINE
SERVICES?
Step 1: Visit the RMA website at: www.randmutual.co.za.
Step 2: Click on the orange “Online Services” tab and then the “Register for Online Services” link.
Step 3: Complete the online registration form and click “Register” once completed. Class XIII members please use your BP number as the CF reference number.
Step 4: RMA’s system will automatically email a username, password and authentication key to your registered email address. The authentication key is used to submit the earnings declarations and claims. You will find this key
as an attachment to the email which you need to save for future use by
right clicking the file and clicking on “Save As” to save it in your selected
folder. Please note that due to the confidentiality of the key, it will not allow you to copy and paste.
24
Rand Mutual Assurance Employer Manual 2016/17
Rand Mutual Assurance Employer Manual 2016/17
25
SECTION 4: REPORTING AN
accident AND SUBMITTING A
CLAIM TO RMA
1. What is my responsibility when my
employee is involved in a work-related
accident?
It is your responsibility as an employer to always have someone available at the organisation who knows what to do, who to phone and how to immediately report
the accident to RMA. All employers have a duty to ensure that an employee receives
immediate and appropriate treatment following an accident. RMA thus encourages
employers to get to know the ambulance services, hospitals, emergency rooms and
doctors in their area and to have the appropriate contact details easily accessible.
The employer should endeavour beforehand to enter into an arrangement with the
healthcare providers in their area to ensure that their employees are treated without
delay when involved in an accident at work.
The employer should explain and prove to the healthcare provider during these discussions that they belong to RMA and that as soon as RMA has accepted liability for a
claim following an accident (usually within three days), medical expenses will be paid
within 10 days from the date when the required documents and medical reports were
received from the employer and the healthcare provider. In order to assist employers,
a letter for injured employees is available from RMA specifically for this purpose and is
available on the Downloads tab of our website www.randmutual.co.za.
The employer should agree with the hospital or doctor concerned how their practice
will be able to identify an employee that belongs to them, and determine if an injury
is work-related. This could be in the form of the printed claim form with the RMA claim
number from C-Filing (please ensure it contains the employer name, employee name
26
Rand Mutual Assurance Employer Manual 2016/17
and the RMA undertaking) or any other means agreed to between the employer and
the healthcare provider such as a letter from the employer.
It is important to note that in terms of section 47(3)(a) of COIDA, the employer is liable
for the payment of compensation for the first three months. The employer therefore
remains liable for the first three months or until RMA has accepted liability.
2. WHEN SHOULD I REPORT AN INJURY OR
DISEASE?
The employee/witness must report the accident to the employer as soon as possible
after it has occurred.
In turn, the employer must report the accident to RMA as follows:
1. Occupational injuries: within
7 Days
of accident.
2.Occupational diseases: within
14 Days
of diagnosis.
Rand Mutual Assurance Employer Manual 2016/17
27
28
Rand Mutual Assurance Employer Manual 2016/17
3. WHAT DO I NEED TO REPORT TO RMA?
All work-related injuries on duty, regardless of the severity of the injury, need to be
reported to RMA. This includes:
• first aid cases
• minor lacerations
• contusions
• abrasions
According to COIDA, if an employee reports an accident alleged to have taken place
in the workplace yet the employer is not convinced it is a work-related accident, it
must still be reported to RMA.
4. WHAT IF I DELAY REPORTING THE INJURY OR
DISEASE TO RMA?
Reporting delays have a serious impact on the claiming and payment process, resulting
in numerous challenges, including:
• Healthcare providers not being paid timeously for services rendered. Delays
in payment could cause the healthcare provider to turn away employees (RMA
patients) in future;
• Temporary Total Disablement (TTD) claims not being submitted timeously and
ultimately delays in payment to claimants;
• Delays in compensation to beneficiaries of a deceased employee;
• Lack of medical reports;
• Black listing of the injured employee; and
• Escalation of costs per claim.
According to section 44 of COIDA, if an accident is reported after 12 months of the
date of the accident or diagnosis of the disease, there is NO benefit available to the
injured/ill employee.
If an employee believes that the employer is not reporting the accident to RMA, they
may approach RMA directly.
Rand Mutual Assurance Employer Manual 2016/17
29
5. HOW DO I REPORT AN Accident TO RMA?
1. Online reporting through C-Filing (RMA’s online claims portal). In
order to report an incident via C-Filing your company needs to be
registered with RMA’s Online Services (see page 24 to register with
online services).
2. Quick and easy telephonic reporting through the RMA Contact
Centre on 0860 222 132.
6. HOW DO I SUBMIT A CLAIM TO RMA?
Please follow the below process when submitting a claim to RMA:
Once the employee has reported the accident to the
employer, the employer must report the accident to RMA
within seven days for an injury and 14 days for a disease.
This can either be done either via:
• C-Filing: Visit www.randmutual.co.za, click on the orange Online Services button followed by the “Claims Submission”
button. Please ensure you are registered with RMA’s Online
Services (see pg 24 to register).
• Telephonic reporting: Call the Contact Centre on 0860
222 132. However, should you be reporting more than five
claims a month, we encourage you to report electronically
via C-Filing. Refer to pg 32 for more information on
telephonic reporting.
Employer completes an Accident or Disease Report Form
(available at www.randmutual.co.za under the Downloads tab)
and keeps on file for record purposes. Where necessary, this
form can be sent with the injured employee to the healthcare
provider as it incorporates all the details of the accident.
30
Rand Mutual Assurance Employer Manual 2016/17
Once the employee has received medical treatment for their
injury or disease, the healthcare provider/employer/employee
must submit a First Medical Report to RMA within 14 days of
the date of the accident. All medical report forms are available
on www.randmutual.co.za under the Downloads tab.
RMA will acknowledge and adjudicate the claim. If liability has
been accepted in terms of COIDA, RMA will pay the healthcare
provider.
Healthcare provider/employer/employee must submit
progress reports during treatment.
Employer submits claims electronically via C-Filing for
Temporary Total Disablement (TTD), also known as “days off”,
of more than three days. These claims must be submitted with
a medical report and/or sick note from the treating doctor.
RMA processes payment to employer for TTD claims.
Employer continues to submit TTD claims for the duration of
the injured employee’s medical treatment.
Once the injury has stabilised the healthcare provider compiles
a final medical report including an assessment of the disability
(where applicable) which is submitted to RMA.
Based on the final medical report and assessment, RMA
calculates the degree of permanent disablement and awards
compensation in terms of COIDA.
In the case of a fatality as a result of the accident,
compensation is paid to the beneficiaries in terms of COIDA.
Rand Mutual Assurance Employer Manual 2016/17
31
7. HOW DO I REPORT AN ACCIDENT
TELEPHONICALLY TO RMA?
Step 1: Employer to call the RMA Contact Centre on 0860 222 132 within seven days for an injury and 14 days for a disease.
Step 2:Have your authentication key (pin number) and member number ready to give to the Contact Centre agent.
Step 3: Employer to supply the following information:
• Name of person reporting the event
• Contact number of the person reporting the
event
• Name of the injured/ill employee
• ID number of the injured/ill employee
• Cell number of the injured/ill employee
• Employee number of the injured/ill employee
• Occupation of the injured/ill employee
• Date of accident
• Time of accident
• Location of accident
• Description of how the accident/disease occurred
• Description and severity of the injury/disease please include the body part, which side of the
body has been affected (right/left/back/front/
multiple) and whether the injury sustained is a
fracture/contusion/laceration/amputation etc.
Step 4: The contact centre agent will take your details and log a referral for a consultant to call you back in order to register the claim.
32
Rand Mutual Assurance Employer Manual 2016/17
Step 5:
Once the claim has been submitted, the system will automatically generate a claim number, known as a personal event number (PEV), which will be given to you by the contact centre agent.
Step 6: A claims assessor will contact you to acknowledge the claim and to send an acknowledgement letter.
8. WHAT INFORMATION AND DOCUMENTATION
DO I NEED TO SUBMIT WITH MY CLAIM?
• Declaration of accident earnings as completed on the Statement of Earnings form
(available on the Downloads tab of the website) (see page 41 to understand more
about accident earnings);
• Copy of ID document;
• Banking details of the injured employee as incorporated in the Statement of
Earnings Form. RMA may request a letter from the bank or a bank statement for the
employee at a later stage should any benefits be payable directly to the employee;
• When benefits are to be paid to the company, the claimant or their dependents,
please include copies of the employee’s payslips for six months prior to the accident;
• For TTD’S, fatal and pensionable benefits – copies of the employee’s payslips for six
months prior to the accident;
• In the case of TTDs, fatal and pensionable benefits, please include copies of the
employee’s payslips for six months prior to the accident.
• RMA First Medical Report (must be submitted to RMA within 14 days of the
healthcare provider having examined/diagnosed the injury/disease);
• RMA Progress Medical Report – in the case of ongoing treatment only; and
• RMA Final Medical Report – when an injured employee has reached maximum
medical improvement (MMI).
• RMA may request additional supporting documentation depending on the
individual circumstances of the claim e.g. police reports in the event of a motor
vehicle accident etc.
Please send all claims related supporting documents required by RMA to:
[email protected]
Rand Mutual Assurance Employer Manual 2016/17
33
9. UNDERSTANDING YOUR CLAIM NUMBER:
Indicates the number of people involved in the accident.
Indicates the class
of the claim
Indicates the type of policy. In this
instance it is a COID claim (EMP =
Employee).
X/1390312/1/A0001/15/EMP
Accident
Number
RMA Member
Number
Year in which the
accident took place
10. How to claim for a multi-person event
34
A multi-person event is an accident in which
a number of people are injured or contract a
disease in the workplace.
In other words, there will be 50 claim numbers
and each of the 50 employees will have their
own unique claim number, as follows:
For example, if 50 people are injured in one
event, when reporting such a case to RMA,
the employer need only report this as one
event and only needs to describe the event
once, and then link the 50 employees to
that one event in the claim number. Each
employee will have an independent claim
but the event will encompass all injured
employees.
Employee 1 – claim number:
X/1491234/1/F0007/2015/EMP
Employee 2 – claim number:
X/1491234/2/F0007/2015/EMP
(Continues as above for all 50 employees)
Employee 49 – claim number:
X/1491234/49/F0007/2015/EMP
Employee 50 – claim number:
X/1491234/50/F0007/2015/EMP
Rand
Rand Mutual
Mutual Assurance
Assurance Employer
Employer Manual
Manual 2016/17
2016/17
11. WHAT IS REQUIRED FOR RMA TO ACCEPT
LIABILITY?
A claim is not a guarantee of payment and only once liability has been accepted
by RMA will a claim be paid. The below information is needed by RMA in order for
liability to be assessed:
• Report the claim electronically via C-Filing or by telephonic reporting.
Depending on your reporting preference, the following are accepted:
o A pin (authentication key or member number) for telephonic reporting; or
o Authentication key (received when registering for Online Services) when
reporting via C-Filing.
• Personal details of injured employee, including:
o ID Number;
o Cell phone number of employee; and
o Company Number.
• A First Medical Report confirming the injury and how it relates to the work of the
employee.
• Accident earnings: (see page 41 to find out more about accident earnings)
o An average of six months earnings prior to the date of the accident (Please
provide payslips for six months or a relevant payroll printout for the six months
when requested);
o Basic earnings;
o Variable earnings;
o Non-variable earnings; and
o Section 51 earnings (where applicable).
12. UNDERSTANDING WHEN TO SUBMIT
MEDICAL REPORTS
Please refer to page 54 for information on submitting medical reports. All medical
report forms are available from www.randmutual.co.za under the Downloads tab.
Rand Mutual Assurance Employer Manual 2016/17
35
13. HOW DO I HANDLE A NOISE INDUCED
HEARING LOSS (NIHL) CLAIM?
In terms of COIDA, an employee or their employer must prove:
• the degree of hearing loss by means of a diagnostic audiogram;
• that the employee is exposed to excessive noise in the workplace. The employee /
employer must prove that the noise is greater than 85 decibels over an eight hour
day or 40 hour week. The higher the intensity of the sound, the less exposure time
is needed for NIHL to occur;
• when the employee first started working in a noise zone by means of the initial
screening audiogram i.e. the baseline audiogram (which could have been
performed at a previous employer) or when the employee first started working for
the employer i.e. entry audiogram; and
• that the type of hearing loss is due to noise exposure and not the various other
causes of hearing loss as confirmed in a medical report.
What documents do I need to submit to RMA for NIHL claims?
• Two diagnostic audiograms conducted on the same day with a reasonable break
between the two audiograms. These should only be conducted after 24 hours of
the employee having been removed from the noisy environment;
• The baseline audiogram;
• Attestation of proof of identity completed by the Audiologist or ear, nose and throat
(ENT) specialist with an attached copy of an ID or passport;
• A full record of service, documenting the noise level exposure for each of the
employee’s occupations or positions during his/ her working career – if the
employee has not been exposed to noise, this should also be recorded as such;
• Medical report compiled by the occupational medical practitioner – this is the
doctor responsible for the occupational health examinations of the company’s
employees; and
• If the percentage hearing loss is greater than 30%, the employee is to be seen by
an ENT specialist. The ENT specialist is to include in the first medical report the full
medical history of the employee, such as treatment with ototoxic drugs, ear surgery
and otitis media.
36
Rand Mutual Assurance Employer Manual 2016/17
14. How do I claim for an employee
working abroad?
In terms of section 23 of the Compensation for Occupational Injuries and Diseases
Act (COIDA), employees ordinarily employed within South Africa but who are injured
while temporarily employed outside of the country are covered as if the accident
happened within the country.
Based on the above, the employee will be covered by RMA if the following criteria
are met:
• the injured employee was temporarily employed outside the country;
• the injured employee was not working beyond the borders of South Africa for a
continuous period of 12 months or more;
• the company’s business operates chiefly in South Africa ;and
• the employee is ordinarily employed in South Africa.
The compensation amount for the injured employee will be based on the earnings
they would have received had they remained in South Africa.
The employer will need to cover all medical costs incurred by the employee while
outside of the country. These costs will be reimbursed by RMA upon proof of payment
and RMA accepting liability for the claim. Medical costs will be reimbursed at South
African COIDA tariff rates.
We request that you keep a record of all medical documents relating to treatment of
the injured employee. This especially important if the employee is repatriated back to
South Africa for further treatment, and for costs to be reimbursed to you if liability is
accepted by RMA.
The employer must notify RMA of any existing employees working outside the borders
of South Africa by completing and submitting a Record of Employee/s working in a
foreign country form to RMA. This form is available on the Downloads tab of the
RMA website at www.randmutual.co.za. This form must be accompanied by a copy
of the employee’s contract of employment as Annexure 1, detailing the working
arrangements whilst the employee is working outside of the country. The form and
contract must be emailed to [email protected]
Rand Mutual Assurance Employer Manual 2016/17
37
The Record of Employee/s working in a foreign country form must include the
following minimum details:
Name of the employee;
Identity number;
Employee number;
Date employed;
Job description;
Employee earnings; and
The period the employee is due to be working outside of the country, including start
and return dates.
Please inform RMA if the company has taken out any additional injury on duty (IOD)
insurance cover. The disclosure must include:
Name of the insurer;
Policy schedule; and
Cover period.
Need an additional solution?
If your company regularly sends employees on international assignments, talk to us as
RMA can partner with you to find a customised solution best suited to your company.
The solution may fall outside of the scope of COID benefits but will ensure that your
risks are minimised and employees are protected while working abroad.
38
Rand Mutual Assurance Employer Manual 2016/17
SECTION 5: COID BENEFITS
There are four main types of COID benefits that can be claimed under COIDA:
•
•
•
•
Temporary Total Disablement (TTD)
Permanent disablement
Death
Medical expenses
1. TEMPORARY TOTAL DISABLEMENT: COIDA
SECTION 47 (DAYS OFF)
Temporary Total Disablement (TTD), also known as a temporary income replacement
benefit, is the payment of an employee for his days off work while injured, or while
recovering from his work-related disease.
TTDs are paid if:
• the employee is off work for more than three consecutive days;
• is undergoing medical treatment; and
• has been booked off by the treating doctor either by means of a medical report or
a sick note for more than three consecutive days.
Based on the supporting medical report or sick note, the employer pays the employee
as per Schedule 4 of COIDA. These payments should be made at regular intervals, but
should not exceed one month intervals. The employer is liable for the TTD payment
for the first three months from the date of the accident. Once RMA has accepted
liability for the claim, the employer is reimbursed for related payments made during
the first three month period.
The employer claims from RMA by submitting TTD claims with the supporting medical
report or sick note either electronically via the C-Filing claims management system
(please remember that your company needs to be registered with RMA’s online services
for this type of claims submission), or by scanning and emailing to RMAscannings@
randmutual.co.za.
Rand Mutual Assurance Employer Manual 2016/17
39
In accordance with COIDA, an injured/ill employee does not receive their full lost
earnings during their absence from work due to injury/illness, however, TTD payments
are tax-free.
Should your company be covered by RMA’s Augmentation policy, which is a top up
cover of the COID benefit, this takes effect if the employee earns above the COID
maximum payment as stipulated above, to a maximum payment of R416 667 per
month.
TTD Payment scenarios
a. Monthly paid employee
Formula: Accident earnings x 75% ÷ 30.3333 x days off = TTDs
Example: Accident Earnings = R10 000
R10 000 x 75% = R7 500 ÷ 30.3333 = R247.25 x 30 Days Off = R7 417.59
b.Fortnightly paid employee
Formula: Fortnightly rate x 2.1666 x 75% ÷ 30.3333 x the number of days off
= TTDs
Example: Fortnightly rate = R5 000
R5 000 x 2.1666 = R10 833 x 75% = R8 124.75 ÷ 30.3333 = R267.84 x 30 Days Off
= R8035.47
40
Rand Mutual Assurance Employer Manual 2016/17
c. Weekly paid employee
Formula: Weekly rate x 4.0 X 75% ÷ 30.3333 x the number of days off =
TTDs
Example: Weekly rate = R1 500
R1 500 x 4.0 = R6 000 x 75% = R4 500 ÷ 30.3333 = R148.35 x 30 Days Off
= R4 450.55
d. Hourly paid employee
Formula: Hourly rate x number of hours worked x 75% ÷ 30.3333 x the number of days off = TTDs
Example: Hourly rate = R40.00
R40 x 320 hours worked = R12 800 x 75% = R9 600 ÷ 30.3333 = R316.48 x 30
Days Off = R9494.51
What is the duration of TTD payments?
TTDs are paid from day four and can continue up to one year (12 months), depending
on the extent of the injury or disease. Once the employee has returned to work or
has received compensation, TTDs can no longer be claimed. If the injury/disease
continues beyond 12 months, RMA will reassess the claim and the possibility of
continuing payment. However, TTDs continuing for more than two years (24 months)
may be considered permanent disablement.
B. What are accident earnings?
Earnings are a key component in the compensation process. They are used to
determine compensation for TTDs, permanent disablement and to compensate
dependents in the event of the employee’s death.
Section 63 of COIDA sets out which earnings are to be used for purposes of
compensation. Variable and non-variable earnings must be reduced to a monthly
amount when submitting claims.
Rand Mutual Assurance Employer Manual 2016/17
41
Which earnings are included and excluded?
1. Earnings include:
• The monthly earnings paid by the employer;
• Food or quarters supplied by the employer;
• Overtime payments for regular work that is ordinarily performed; and
• Any allowance of a regular and constant nature.
2.Earnings exclude:
• Payment for intermittent overtime;
• Payment for non-recurrent occasional services;
• Amounts paid by an employer to an employee to cover any special expenses; and
• Ex-gratia payments whether by the employer or any other person.
What are variable and non-variable earnings?
1. Non-variable earnings:
These are consistent earnings and include:
• the employee’s basic salary;
• any housing allowances; and
• any annual or incentive bonuses.
It is important here to note that:
(i)If the employee’s basic salary fluctuates, or is increased during the six month period
that has already been declared, then an average must be calculated for the six
months’ basic salary.
(ii)The annual bonus and/or incentive bonus (if applicable) must be divided by the number of months for which it is payable. For example if it is paid annually then it
must be divided by 12.
If it is paid biannually, then it must be divided by six, or if per quarter then by
three. This is then the amount that is declared per month.
42
Rand Mutual Assurance Employer Manual 2016/17
For example:
Annual bonus: R5000 ÷ 12 = R416,66
This is the amount placed in the annual bonus field when completing the accident/
disease report form or section 51 forms.
2. Variable earnings
These are less consistent earnings and constitute the cumulative allowances the
employee received during the six months before the accident. These allowances
can be for overtime worked, production bonuses and attendance bonuses etc. The
cumulative amount is then divided by six to determine the amount to be declared as
variable earnings.
Earnings declaration compensation for an employee in training or under the
age of 26
If the employee is under the age of 26 or working as an apprentice at the time of the
accident, it falls under section 51 of COIDA, and the earnings are calculated on future
earning potential.
In the case of an apprentice, the calculations are based on the earnings of a recently
qualified person or a person in the same occupation, trade or profession with five
years’ experience, whichever is more favourable to the employee.
Similarly, in the case of an employee under the age of 26, his/her earnings are based
on the earnings that a person of 26 years would normally have been entitled to if
performing the same work as the employee at the time of the accident.
Alternatively, the calculations are based on the earnings of an employee in the same
occupation, trade or profession with five years’ experience, whichever calculation is
more favourable to the employee.
Rand Mutual Assurance Employer Manual 2016/17
43
2. PERMANENT DISABLEMENT
A. LUMP SUM PAYMENT: COIDA SECTION 49
Permanent Disablement awards from 1% to 30% are paid in the form of a lump sum.
The lump sum amount that is paid to the injured employee is based on the degree
(percentage) of permanent disablement. This is calculated once the injured employee
has been assessed and the Final Medical Report has been submitted to RMA. The
percentage of permanent disablement is set out in Schedule 2 of COIDA.
Permanent disablement percentages as per Schedule 2 of COIDA
Injury
% permanent
disablement
Loss of two limbs
100
Loss of both hands, or of all fingers and both thumbs
100
Total loss of sight
100
Total paralysis
100
Injuries resulting in employee being permanently bedridden
100
Any other injury causing permanent total disablement
100
Loss of arm at shoulder
65
Loss of arm between elbow and shoulder
65
Loss of arm at elbow
55
Loss of arm between wrist and elbow
55
Loss of hand at wrist
50
Loss of four fingers and thumb of one hand
50
Loss of four fingers
40
Loss of thumb:
44
both phalanges
25
one phalanx
15
Rand Mutual Assurance Employer Manual 2016/17
Permanent disablement percentages as per Schedule 2 of COIDA (Continued)
% permanent
disablement
Injury
Loss of index finger:
Loss of middle finger:
Loss of ring finger:
Loss of little finger:
Loss of metacarpals:
Loss of leg:
Loss of toes:
three phalanges
10
two phalanges
8
one phalanx
5
three phalanges
8
two phalanges
6
one phalanx
4
three phalanges
6
two phalanges
5
one phalanx
3
three phalanges
4
two phalanges
3
one phalanx
2
first, second or third
(additional)
4
fourth or fifth (additional)
2
at hip
70
between knee and hip
45 to 70
below knee
35 to 45
all
15
big, both phalanges
7
big, one phalanx
3
toes other than big toes:
four toes
7
three toes
5
two toes
3
one toe
1
Rand Mutual Assurance Employer Manual 2016/17
45
Permanent disablement percentages as per Schedule 2 of COIDA (Continued)
% permanent
disablement
Injury
Loss of eye:
Loss of hearing:
whole eye
30
sight
30
sight except perception of
light
30
both ears
50
one ear
7
Please also note the following:
• Total permanent loss of the use of a limb is treated as the loss of the limb.
• Any injury to the left arm or hand and, in the case of a left-handed employee, to the
right arm or hand, may at the discretion of RMA be rated at 90%.
• If there are two or more injuries, the sum of the percentages for these injuries may
be increased, at the discretion of RMA.
How to calculate a PD lump sum
The formula to calculate a PD lump sum is as follows:
Formula: Accident earnings x 15 x disability % ÷ 30 = PD lump sum
For example:
46
Multiply the employee’s accident
earnings by 15
Multiply by the disability %
Accident Earnings: R9 500
R9500 x 15 = R142 500
R142 500 x 10 = R1 425 000
(the “10” indicates the percentage
value of the permanent disablement)
Divide the answer by 30
R1 425 000 ÷ 30 = R47 500
Rand Mutual Assurance Employer Manual 2016/17
B. PERMANENT DISABLEMENT PENSION: COIDA SECTION 49
Section 49 of COIDA prescribes a monthly disablement pension for all permanent
disablement (PD) awards greater than 30%. The monthly pension is payable for the
life of the disabled employee.
How to calculate a PD pension (31%-100%)
The formula to calculate a monthly PD pension for employees with an injury
between 31% and 100% is as follows:
For example:
Multiply the employee’s accident
earnings by 75%
Multiply the above amount by the
percentage of permanent disablement
(in this case it is a 50% PD)
Accident Earnings: R9 500
R9500 x 75% = R7 125
R7 125 x 50% = R3 562.50
(the “50%” indicates the percentage
of the permanent disablement)
R3 562.50 is the normal pension amount RMA will pay to the injured employee on a
monthly basis for his life.
If the employee is unable to perform essential life activities without the constant
help of another person as a result of their disablement from the accident, they are
paid an additional constant attendance allowance. This is a fixed monthly amount as
stipulated by COIDA.
Rand Mutual Assurance Employer Manual 2016/17
47
3. DEATH BENEFITS
Section 54 of COIDA determines the compensation award following the death of
an employee in a work-related accident, or as a result of an occupational injury or
disease.
If the employee dies, the following applies:
1. If the death is due to the occupational injury/disease, a continuing fatal benefit will
be paid to the deceased employee’s dependents. Dependents are defined as per
section 1 of COIDA (see definition on page 20).
2.If the employee is an RMA pensioner and if the death is not as a result of the
occupational injury/disease, the pension ceases.
The following are the benefits payable in the event of a fatal claim:
a)Spouse’s lump sum payment
b)Spouse’s monthly pension
c)Dependent children’s monthly pension/s
d)Funeral benefit
48
Rand Mutual Assurance Employer Manual 2016/17
a) Spouse’s lump sum payment
This is a once-off lump sum payment paid to the spouse. If the deceased employee
had more than one spouse married in terms of customary law, this payment is shared
between the spouses.
Formula: Accident earnings x 75% x 2 = lump sum payment
For example (1 spouse):
Multiply the employee’s accident earnings by 75%
Multiply the amount by 2
Accident Earnings: R9 500
R9500 x 75% = R7 125
R7 125 x 2 = R14 250
If there are additional spouses, the R14 250 will be divided by the number of spouses.
b) Spouse’s pension
The spouse’s pension is a lifelong monthly benefit of 40% of 75% of the deceased’s
accident earnings.
Formula: Accident earnings x 75% x 40% = spouse’s monthly pension
For example (1 spouse):
Multiply the employee’s accident
earnings by 75%
Multiply the amount by 40%
Accident Earnings: R9 500
R9500 x 75% = R7 125
R7 125 x 40% = R2 850 per month
If there is more than one spouse, the amount of R2 850 is divided by the number of
spouses.
Rand Mutual Assurance Employer Manual 2016/17
49
c) Child/ren’s pension
The child’s pension is a monthly benefit of 20% of 75% of the deceased’s accident
earnings if there are three or less children.
For example:
Multiply the employee’s
Accident Earnings: R9 500
accident earnings by 75%
R9500 x 75% = R7 125
Multiply the amount by 20%
R7 125 x 20% = R1 425 per child per month
This benefit is payable to each minor child until the month in which the child turns
18 years. Where there are more than three children, the 60% (i.e. 20% x 3) is divided
equally by the number of children. Where employers have taken RMA’s Augmentation
Policy as a separate benefit, this will take effect in cases where there are more than
three children.
A child may apply to RMA for an extension beyond 18 years under the following
circumstances:
• If the child is unable to earn an income due to a physical or mental disability;
• If the child is still completing secondary education; or
• If the child is undergoing tertiary education.
The extension of a child’s pension is discretionary and RMA will assess the merit of
each case individually.
If the child dies or marries before the age of 18 years, his/her benefit will cease.
d) Funeral benefit
RMA pays a fixed funeral benefit as is annually gazetted by the Minister of Labour.
50
Rand Mutual Assurance Employer Manual 2016/17
4. What are the COID benefits for
2016/17?
In accordance with Schedule 4 of Government Gazette No. 39683, the COID benefits
from 1 April 2016 to 31 March 2017 are calculated as follows:
(ii)
(i)
(iii)
(iv)
(v)
Item Section Nature and Nature of Manner of
benefits
calculating
degree of
benefits
disablement
1.
2.
3.
4.
5.
6.
(vi)
(vii)
Recommended Recommended
maximum
minimum
compensation compensation
R23 569
47(1)(a) Temporary Periodical 75% of an
R3 300
payments employee’s
total
monthly earnings
disablement
at the time of the
accident.
15 x the monthly R263 991
49(1)
Permanent Lump
R65 993
earnings of the
disablement sum
employee at
of 30%
the time of the
accident.
The lump sum benefits specified in item 2 above are
Permanent Lump
49(1)
prorated according to the disability % up to 30%.
disablement sum
of less than
30%
R23 569
Permanent Monthly 75% of an
49(1)
R3 300
employee’s
disablement pension
monthly earnings
of 100%
at the time of the
accident
Permanent Monthly The monthly pension benefits specified in item 4
49(1)
above are prorated according to the disability %,
disablement pension
between 30% and 100%.
of less than
100% but
more than
30%
R47 138
Lump
Twice the
54(1)a Fatal
R6 600
employee’s
sum
monthly pension
that would have
been payable to
the employee
under item 4 had
he been totally
disabled.
Rand Mutual Assurance Employer Manual 2016/17
51
(i)
(ii)
(iii)
(iv)
(v)
Item Section Nature and Nature of Manner of
benefits
calculating
degree of
benefits
disablement
52
7.
54(1)b
Fatal
8.
54(1)c
Fatal
9.
54(1)
(d)(ii)
Fatal
10.
54(2)
Fatal
11.
63(1)(a) Minimum
for free
food and
quarters
12.
28
Constant
attendance
allowance
Monthly
Pension
(vi)
(vii)
Recommended Recommended
maximum
minimum
compensation compensation
R9 428
R1 320
40% of the
monthly pension
that would have
been payable to
the employee
under item 4 had
he been totally
permanently
disabled.
R4 714
Monthly 20% of the
pension
monthly pension
that would have
been payable to
the employee
under item 4 had
he been totally
permanently
disabled, to each
child.
R135 797
Percentage
Lump
sum
dependence as
portion of R135
797 based on a
standard formula.
R17 218
A reasonable
Funeral
amount for
costs
funeral costs to
a maximum of
R17 218 or the
actual amount,
whichever is the
lesser.
Minimum for
To be
included free food R237
per month and
in
earnings minimum for free
quarters R106 per
month.
Monthly Minimum
allowance amount of R1 759
per month.
R660
R237 per
month for free
food and R106
per month for
free quarters
R1 759
Rand Mutual Assurance Employer Manual 2016/17
5. MEDICAL EXPENSES
Once RMA has accepted liability on a claim, all reasonable medical expenses related
to the occupational injury/disease will be paid for up to two years from the date of
the accident or diagnosis of the disease. These benefits are paid to a maximum of the
COIDA tariff (which is updated annually on 1 April), per diem and negotiated tariffs.
If no amount has been determined for a particular medical treatment, RMA will not
pay more than what is deemed reasonable by the Director-General as per section 76
of COIDA.
Pre-authorisation of medical benefits
Pre-authorisation assists healthcare providers with confirmation that RMA has taken
liability for the cost of treatment, and is thus a form of guaranteed payment. Preauthorisation can only be generated, however, once the incident has been reported
to RMA and liability has been accepted.
In an emergency, medical treatment should continue without pre-authorisation, which
can then be obtained retrospectively.
Whilst pre-authorisation is not a pre-requisite for treatment in emergency or acute
cases, it is recommended that the hospital (or healthcare provider) notifies RMA of all
hospital admissions in order to assist with confirmation of RMA liability.
Re-opening of a claim
Authorisation is, however, compulsory if a claim has been finalised, but where further
medical treatment is indicated or required and RMA is expected to pay the medical
costs of the re-opened claim. The objective of the requested treatment should be
focussed on further reducing the impairment.
In the case of a re-opening of a claim for specific treatment, the healthcare provider
is required to submit a request with supporting documents to RMA which will review
the merits of the request and, if valid, approve liability through the process of preauthorisation.
Rand Mutual Assurance Employer Manual 2016/17
53
Physiotherapy and Occupational Therapy pre-authorisations
No pre-authorisation is required for the first 20 sessions with either a physiotherapist
or occupational therapist. Thereafter, pre-authorisation is required together with a
treatment plan. Should the additional sessions not be pre-authorised, these will not
be paid by RMA.
Medical reports required by RMA
A first medical report must accompany the first consultation. Thereafter, progress
reports must be submitted for ongoing treatment and consultations with doctors,
specialists, psychologists and psychiatrists. A progress report can cover multiple visits
for up to, but not exceeding, a month. However, should there be a change in the
claimant’s medical condition, an updated medical report must be submitted to RMA.
Even if pre-authorisation has been obtained, if there is no accompanying medical
report, the doctor’s invoice for that service date will not be paid.
For on-going treatment, RMA needs to be informed of the progress of the claimant’s
medical condition at least once a month. Days taken off work and when the employee
will resume work must be indicated as well as justification for the temporary total
disablement. Supporting documents and any paid invoices must be submitted to
RMA.
Should the claimant consult an allied health professional (physiotherapist, chiropractor,
occupational therapist, biokineticist, dietician etc.), a referral letter from the treating
doctor and a medical report from the allied professional must be submitted at the
beginning of the treatment and again at the end of the treatment.
Once the claimant has reached Maximum Medical Improvement (MMI), the point
beyond which his/her condition will neither improve nor decline, a final medical report
must be submitted to RMA. This medical report will be used to assess functional loss
and will determine whether the claimant should receive a permanent disablement
benefit. RMA’s role and function is not to assess the employee’s fitness to return to work.
54
Rand Mutual Assurance Employer Manual 2016/17
This is the responsibility of the employer, taking the inherent risks and requirements of
the employee’s specific job into account.
Please note that all medical report forms are available on RMA’s website
www.randmutual.co.za under the Downloads tab.
Are there any co-payments for medical treatment?
Under no circumstances should the employee pay either a co-payment or an
administration fee to the healthcare provider. Should this be the case, the employer
must inform RMA.
Similarly, if the employer or employee are aware of a healthcare provider charging out
of tariff rates, they should inform RMA in order that we may address this individually
with the relevant healthcare provider.
When will RMA not pay COID compensation?
Claims will only be paid if they are submitted in the correct way within the proper time
limit.
According to COIDA, a compensation claim will not be paid if:
• the claim is submitted to RMA more than 12 months after the injury or death, or
more than 12 months after the disease is diagnosed;
• if the employee was off work for three days or less, TTDs and permanent disablement
may not be paid by RMA, however, medical costs will be paid;
• the accident or injury is a result of an employee’s wrong doing or misconduct,
unless the employee was seriously disabled or died as a result of the accident; and
• the employee unreasonably refuses to have medical treatment.
Rand Mutual Assurance Employer Manual 2016/17
55
56
Rand Mutual Assurance Employer Manual 2016/17
SECTION 6: REVIEWS/APPEALS
Section 91 objections
Should the employee, employer or trade union representative not agree with a
a decision made by RMA, section 91 of COIDA entitles the employee to lodge an
objection against the decision. A section 91 objection must be lodged within 180 days
of the decision made by RMA and will be heard by an independent tribunal. The
objector may be appear in person at the tribunal or may be represented by a trade
union or legal representative. Should the employee still not agree with the outcome
of the tribunal, they may further appeal the decision in the High Court in terms of
section 91(5)(a) of COIDA.
Appeal Process
Employee unhappy
with PD award
decision by RMA
Completes an
RMA section 91
objection form
Independent
tribunal
RMA legal
department
communicates
tribunal outcome
Section 56 objections
If an employee has an accident due to negligence by the employer or an employee in
management, the employee may make an application for increased compensation
over and above the standard compensation.
An RMA Section 56 application form must be submitted to RMA within two years (24
months) of the date of the accident. RMA shall investigate the accident and make a
decision regarding the alleged negligence.
Rand Mutual Assurance Employer Manual 2016/17
57
SECTION 7: TRAINING
RMA offers a comprehensive training solution for stakeholders to ensure a sound
understanding of its products, processes and its simple, accessible online facilities.
In order to make sure that your training needs are sufficiently supported, RMA offers
training workshops around the country. RMA drafts a training schedule at the beginning
of each year, which is available on www.randmutual.co.za under the User Zone Training link. However, should you require specific training for your company, please
contact us on [email protected] and we will investigate the possibility
of scheduling a workshop in your area. Please note, however, that a minimum of 15
people are required in order for a workshop to take place.
Alternatively, RMA offers additional training solutions to assist you, as follows:
1. ONLINE SYSTEM TRAINING
RMA’s online learner management system allows for ease of use and can be accessed
at your convenience, 24 hours a day, seven days a week.
Once you have registered with RMA’s online services (see pg 24 on how to register)
you will automatically receive a link, together with your username and password, that
will direct you to the log in page. Once received, please save this link as a favourite
(ctrl D) for ease of future access.
Once logged in to the Learner Management System, you will have access to the
following:
• Online Training
o C-Filing Simulator (C-Filing is the claims management module on the RMA
system)
• RMA Training videos
o Employer Information Briefing
oThe Claims Cycle
• Training Schedule for the year
58
Rand Mutual Assurance Employer Manual 2016/17
2. LIVE WEBINARS
In addition, RMA hosts “live” member workshops via Webex. These online workshops
cover the following:
Member Workshop
• RMA overview
• RMA mandate
• RMA products and earnings declarations
• Occupational injuries and diseases
• Employer obligations and penalties
• Document completion and submission
• General discussion – Q&A
C-Filing (claims management system)
• RMA overview
• Introduction to C-Filing (RMA’s claims management system)
• User roles – electronic signature
• Step-by-step claim submission
• Statement of earnings form
• Capturing of days off invoice
• General discussion – Q&A
To participate in the webinars, please submit a RMA Webex training request form,
select your preferred date and forward to [email protected]. Once
RMA has received your confirmation, we will forward a link that will give you access to
the relevant Webex workshop.
Please accept this link before the actual workshop in order to ensure timeous dialing
into the workshop. You will also receive a guide to assist you to better navigate Webex.
Should you have any queries regarding the above, please contact us on 010 214 3179
or [email protected]
Rand Mutual Assurance Employer Manual 2016/17
59
SECTION 8: FRAUD
If you suspect fraud – either by an RMA employee or by any of our clients, healthcare
providers or suppliers - don’t delay, contact the anonymous RMA fraud and ethics line
as soon as possible.
The RMA fraud and ethics line is managed by Deloitte through Tip-offs Anonymous and
is therefore totally independent of RMA, ensuring anonymity. No one will therefore
ever know who reported the fraud or the dishonest and inappropriate behaviour.
Fraud line (inside SA):
0800 21 22 56
Fraud line (outside SA):
+27 31 571 5734
FreeCall fax:
0800 00 77 88
Email: [email protected]
FreePost address: Tip-offs Anonymous,
FreePost KZN 138,
Umhlanga Rocks,
4320
60
Rand Mutual Assurance Employer Manual 2016/17
Rand Mutual Assurance Employer Manual 2016/17
61
SECTION 9: CONTACT US
Tel: 0860 222 132
Fax: 0860 222 203
Enquiries: [email protected]
Document submissions: [email protected]
Postal Address: P O Box 61413, Marshalltown, 2107
Website: www.randmutual.co.za
Got an enquiry, compliment or complaint? We want to hear from you. Please
complete the feedback form under the Contact Us tab on www.randmutual.co.za.
RMA Branches:
62
Head Office
BDO Building,
1st Floor,
22 Wellington Road,
Parktown
Carletonville
Terenure Building,
124 Kaolin Street,
Carletonville
Durban
Mayfair on the Lake,
3rd Floor,
5 Park Lane,
Parkside,
Umhlanga Rocks
Johannesburg
23 Wellington Road,
Parktown
Klerksdorp
Ground Floor,
Sanlam Building,
President Kruger
Street,
Klerksdorp
eMalahleni
Unit 505 5th Floor
Centre de la vie
Corner Beatty
Avenue and
Woltemade Street
(Opposite Life
Cosmos Hospital)
eMalahleni
Maseru – Lesotho
(Satellite Office)
TEBA Office,
226 Moshoeshoe
Road, Industrial Area,
Lesotho
Tel: (+26) 6 22 314
897
Mthatha (Satellite
Office)
TEBA Office,
9 York Road,
Mthatha
Pretoria
Podium at Menlyn,
3rd Floor,
43 Ingersol Road,
Corner Lois and
Atterbury Roads,
Menlyn
Rustenburg
Montana Building,
Corner Loop and
Van Alphen Streets,
Rustenburg
Welkom
2 Toermalyn Street,
Jan Cilliers Park
(Extension 7),
Welkom
Xai-Xai –
Mozambique
(Satellite Office)
Bairro 6 coca missava,
recinto da Wenala,
casa #3
Tel: (+258) 282 6990
Rand Mutual Assurance Employer Manual 2016/17
Rand Mutual Assurance Employer Manual 2016/17
63
Notes
64
Rand Mutual Assurance Employer Manual 2016/17