Tshiamiso Trust collaboration helps reduce pipeline of deferred, incomplete claims 

25th August 2023

By: Cameron Mackay

Creamer Media Senior Online Writer


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Compensation fund Tshiamiso Trust CEO Dr Munyadziwa Kwinda has noted that collaboration with the Medical Bureau for Occupational Diseases (MBOD), mining consultancy TEBA and the departments of Home Affairs and Health has resulted in the trust reducing its pipeline of deferred and incomplete claims.

Speaking at the trust’s virtual yearly general meeting on August 25 – during which the trust provided an overview of operations and financial statements for the financial year ending February 28 this year – Kwinda pointed out that this collaboration had resulted in the trust reducing its pipeline of deferred incomplete claims in the reporting period by 60%, from 17 179 to 6 820.

“During the reporting period, there were 36 965 claims that were launched. This led to a cumulative number of lodgements since the inception of the trust to 111 451. We also managed to search for service records in respect of 4 366 individual mineworkers who are potential clients not yet on our database.

“These records of service are not only critical for the claim process and to free benefits medical examinations (BME) services if the mineworker did more than five years of risk work, but also determines the award calculation based on any applicable payment benefit modifiers.

“It is, however, rare for all the required documentation to be submitted at the lodgement stage. This results in a high number of incomplete claims that we’re unable to process. A large portion of disease claims lack the supporting medical records required to enable the adjudication of claims by medical certification partners.”

Kwinda did, however, stress that the trust faced the challenge of about 30% of claims being uncontactable post lodgement owing to claimants’ contact numbers being incorrect or changing.

As a result, the trust is unable to contact these claimants to schedule BMEs or request missing or incomplete documents to finalise claims.

“Those who are required to go through the medical BMEs will go directly to the trust certification committee, and the disease claims will also not be subjected to the BMEs.

“During the reporting period, we had done 15 051 BMEs, and then at the end of the financial year we had done 46 736 BMEs. These are done by a network of fixed BME sites and also mobile sites on rotation to reach claimants as close to their homes as possible.”

The trust is also able to contact a specific category of claimants who are not able to travel to mobile sites, he added, as BMEs were done in the homes of these claimants.

Kwinda pointed out that by the end of the reporting period, there was a backlog of 14 237 BMEs, owing to a number of reasons.

These include claimants being uncontactable, he noted, adding that this backlog was also owing to an unavailability of BME services in specific countries, such as eSwatini, Mozambique and Botswana.

Further, he pointed out that there were also pending BMEs for mineworkers who did less than five years of qualifying risk work, and, therefore, need to pay for their own BMEs. This has also contributed to the backlog, as these mineworkers have to wait until they are able to pay for the BMEs, which cost about R900.

If claimants report that the trust cannot perform free BMEs and they pay for their own BMEs, they and are later found to be eligible for BMEs, the R900 is reimbursed back to these claimants, he added.

“Regular audits and quality checks of medical service providers and BME outcomes remain ongoing to ensure that the services rendered are in accordance with the trust policies, and that the required trust deed and local and international industry standards are met. After BMEs, we have the medical certification. That is where all the claims, except the claims that go straight to the Trust Certification Committee, will have to be considered by the Medical Certification Panel (MCP).

“This is where things start to change for claimants who have been hopeful to receive compensation. It is at this stage where medical certification is done. The MCP had 63 823 sittings during the period in review, bringing us to a total of 91 847. This is an increase of 277%, year on year, from the 23 024 completed in the previous period, and 67% of the cumulative total.

"More than 55 490 claims will be medically certified by the end of the reporting period, and 74%, which is 40 799 of these, took place during the reporting period. Fifteen thousand of the certified claims were found to be medically eligible, translating into a 28% medical eligibility rate.”

Out of ten claimants that go through the MCP, about three become medically eligible, which he pointed out claimants are unhappy with.

“There is, however, a Reviewing Authority that has started operations this year. This allows claimants to lodge another claim if there are additional documents to be submitted and considered, and that is the last chance a claimant has. A claimant can also lodge a dispute with the Medical Reviewing Authority.

''More than 8 300 claims were deferred for further investigation or documentation by the end of the reporting period. There are different reasons why claims are deferred, some of which deal with the issues of the death certificates and post-mortem reports, or quality of the X-ray procedures that are done.”

He stressed that the trust had experienced difficulties progressing tuberculosis (TB) claims for leaving mineworkers, particularly related to documentation, including TB test results and proof of completion of treatment, as well as some dependant claims for silicosis and TB. This has affected a number of claimants who lodged claims as far back as February 2021.

Further, he added that the trust had experienced delays for TB and silicosis category claims for mineworkers that passed away before December 10, 2019.

For these claims, TB or silicosis must be indicated as the primary cause of death on either the official death certificate, or a post-mortem report.

“In South Africa, families are issued with an abridged death certificate, which does not disclose the primary cause of death. The primary cause of death will be contained in the death notification form. When medical practitioners complete this form, however, the form is sealed, as the information about the deceased is confidential.”

Owing to this, the Trust has asked claimants to apply for supplementary documentation from the Department of Health. An unabridged death certificate is likely to contain the primary cause of death, and costs R75 if one goes to Home Affairs directly.

“The other acceptable document, a post-mortem examination report, also presented challenges resulting in the Trust being unable to progress claims that rely on post-mortem examination reports. Uncertainty stemmed from the fact that such reports do not state the primary cause of death which needs to be resolved. This also applies to those who have already received a certificate of medical finding, saying that they are eligible.

"The third major challenge relates to obtaining letters of authority required for diseased mineworkers who died after December 10, 2019. The courts are unwilling to issue these documents without evidence of the amount of money owing to the claimant, and the Trust is not able to process these claims without these letters. We are engaging with the Masters Office of the Department of Justice and facilitating necessary changes to allow these claims to progress,” he explained.

Edited by Chanel de Bruyn
Creamer Media Senior Deputy Editor Online




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