THE COMPENSATION FUND Dr Lucas Mosidi Director: Medical Services 1 1
Rehabilitation, Return-to-Work (and the Law) 2
TABLE OF CONTENTS • Mandate of the Fund 1 • Vision and Mission 2 • Core Business Units 3 • Our Strategic Rehabilitation Pillars 4 • Our Case Management Approach 5 • Our Rehabilitation Logic Model 6 • Patient-centred Approach 7 • The Legislative Framework 8 • Strategic (Re) Focus 9 • Strategic Policy Framework 10 • The Coid Amendment Bill 11 • Responsibilities of Stakeholders 12 • Desired End State 13 2019/05/06 3
MANDATE Constitutional • Established in terms of Section 27(1)(c) of the Constitution under the Bill of Rights to provide Mandate social security and appropriate social assistance • To provide compensation for disablement caused by Legislative occupational injuries or diseases sustained or contracted by employees or for death resulting from Mandate such injuries or diseases and provide for matters connected therewith. Statutory • The Compensation Fund is established in terms of Section 15 of the Compensation for Occupational Establishment Injuries and Diseases Act as amended 2019/05/06 4
VISION & MISSION Our Vision Our Mission To be a world-class provider of sustainable compensation for occupational injuries To provide efficient, quality, client-centric and diseases, rehabilitation and and accessible COID service reintegration services To sustain financial viability To ensure an organization which takes care of the needs of its staff for effective service delivery 2019/05/06 5
CORE BUSINESS UNITS COID Services Insurance Underwriting and Beneficiary Services • Claims Registration and Adjudication • Benefit Payment ( TTD, TD, CCA, Fatal Benefits, Funeral Benefits, Pensions) • Employer Registrations • Return of Earnings and Assessments • Compliance and Audits Medical Benefits Medical Aid • Medical Services ( Policy and Regulation services) • Medical Claims (MSP Registrations, Medical Aid, Tariff Determinations, Electronic Invoice Switching) • Managed Care (Pre-authorisations, Case Management) Rehabilitation Services Employee Reintegration Services • Vocational Rehabilitation Programmes • Social Reintegration Programmes • Provision of Assistive Technology 6
OUR STRATEGIC REHABILITATION PILLARS Medical Rehabilitation Vocational Rehabilitation Social Reintegration Provision of Assistive Technology 7
OUR CASE MANAGEMENT APPROACH Medical Treatment Injury/ Disease Management Medical Rehabilitation Injury/ Case Occupational Vocational Management Disease Rehabilitation Social Rehabilitation Reintegration Assistive Technology Active Involvement of all Stakeholders at every stage of Care Medical Service Employers Trade Unions Employees Compensation Fund Providers 8
OUR REHABILITATION LOGIC MODEL Objective Strategy Output Outcome Performance Indicator Sustainable Social Functional & Social % Rehabilitated & Managed Care Quality Rehabilitation Security Independence Reintegrated 9
PATIENT-CENTRED APPROACH Employer Medical Employee OHNP/OMP Service (Beneficiary) Provider The Fund 10
THE LEGISLATIVE FRAMEWORK Basic Conditions of Employment Section 27(1)(c): Everyone has Section 22: Sick Leave – 36/12 cycle Constitution (The Bill of Rights) Act (BCEA 75 of 1997) the right to have access to social Section 23: Proof of Incapacity – Sick security, including, if they are note if absent 2 days or more unable to support themselves Section 24 : Application to and their dependents, occupational accidents or diseases – appropriate social assistance. Nullifies Sections 22 & 23 Section 27(2): The state must Section 25: Maternity Leave – 4/12 take reasonable legislative and Section 26: Protection of employees other measures within its before and after birth of a child- (1) available resources, to achieve No hazardous work; (2) Suitable or alternative employment on same the progressive realization of terms for six (6) months post-natally each of these rights if (a) Night Work and (b) Reasonably Section 27(3): No one may be Practicable refused emergency medical Section 83: Deeming of persons as treatment employees Section 87(1)(b): Code of Good Practice on the Protection of Employees during Pregnancy and after the Birth of a Child. 11
THE LEGISLATIVE FRAMEWORK 55 of 1998) Labour Relations Act (LRA 66 Employment Equity Act (EEA Section 5 : Employer to promote Section 185: Right to not be of 1995) equal opportunity and eliminate unfairly dismissed or subjected to unfair discrimination in all policies Unfair Labour Practice and practice Section 186(1): Meaning of Section 6 (1): Prohibition of unfair Dismissal discrimination on the basis of disability Section 186(2): Meaning of Unfair Labour Practice Section 7(1): Prohibition of Medical testing Section 187: Automatically Unfair Section 8: Prohibition of Dismissals: (1)(e): Pregnancy, psychological testing intended pregnancy or any reason related to pregnancy; Section 9: Employee includes applicant of employment (1)(f): race, gender, sex, ……disability,etc. Section 15: Affirmative action measures 2(a) identify and eliminate Section 200A(4): Code of Good employment barriers 2(c) reasonable Practice on Who Is an Employee? accommodation of designated groups Section 133: Dispute resolution (3) Preferential treatment of through Commission (CCMA) designated groups 12
THE LEGISLATIVE FRAMEWORK Mine Health & Safety Act Occupational Health & Safety (MHSA 29 of 1996) Section 5: Employer to maintain Section 3(1): Employer to ensure Act (OHSA 85 of 1993) healthy and safe mine environment first aid treatment in case of injury or emergency Section 11: Employer to assess and respond to risk Section 8(1): Employer to provide Section 12: Employer to conduct and maintain safe working occupational hygiene measurements environment Section 13: Employer to establish Section 8(2)(b-d): Employer to system of medical surveillance,; read identify, assess, evaluate and in conjunction with Sections 14 – 20 . mitigate occupational hazards Section 22: Employees’ duties for Section 14 (a): Responsibility of health and safety employee towards health & Section 23: Employees’ right to leave safety; (c) abide by lawful dangerous working place instruction; (e) immediate Section 54: Inspector’s power to deal reporting of injuries with dangerous conditions Sections 24 & 25: Employer to Section 55: Inspector’s power to ensure reporting of all work- order compliance related injuries and occupational Section 86: Negligent act or omission diseases 13
THE LEGISLATIVE FRAMEWORK Compensation for Occupational Injuries Compensation for Occupational Injuries & Diseases Act (CODA 130 of 1993- cont.) Section 22: Right to Compensation; Section 66: Presumption regarding & Diseases Act (COIDA 130 of 1993) read in conjunction with Sections 38 cause of occupational disease; read in – 41 . conjunction with Sections 65 & 68. Section 26: Special circumstances in Section 73: Medical expenses; read in which the Director-General may conjunction with Sections 72 & 74. refuse award Section 75: Director-General to Section 28: Employee requiring decide on need for, and nature and constant help sufficiency of, medical aid. Section 29: Liability for payment of Section 76: Fees for medical aid; read compensation in conjunction with Sections 77 & 78 . Section 42: Employee to submit to Section 79: Consultation of medical examination representative medical authorities by Director-General. Section 44: Prescription Section 85: Variation of tariff of Section 45: Consideration of claim; assessment read in conjunction with Sections 47 – 49. Section 90: Review of decisions by Director-General Section 56: Increased compensation due to negligence of employer Section 91: Objections and appeal against decisions of Director-General 14
STRATEGIC (RE)FOCUS Grow Social Safety Net Disability Improve Claims Management Turnaround Times Active Case Rehab Management & RTW Rehabilitation & Active Case RTW Management Disability Management Improve Claim TAT Grow Social Safety Net Current Focus Business Process Reengineering Future Focus 2019/05/06 15
STRATEGIC POLICY FRAMEWORK Driven by CF in accordance with Ensure enabling Aligned to the vision and its RR/RTW Policy Framework strategic objective of the Fund legislation and COIDA Responsive to the call of the With the ultimate aim of NDP Vision 2030 to create an Developed in collaboration with addressing the needs of the inclusive social protection all stakeholders most vulnerable system (injured/diseased employees) Outlines the rights, roles and Puts special emphasis on the Encourages evidence-based responsibilities of all need for health promotion and methodologies and best practice stakeholders disease and injury prevention across the board Based on a biopsychosocial approach which takes into account medical, psychological and social aspects 2019/05/06 16
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