THE COMPENSATION FUND Dr Lucas Mosidi Director: Medical Services 1 - - PowerPoint PPT Presentation

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THE COMPENSATION FUND

Dr Lucas Mosidi Director: Medical Services

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Rehabilitation, Return-to-Work (and the Law)

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TABLE OF CONTENTS

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• Mandate of the Fund

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• Vision and Mission

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• Core Business Units

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• Our Strategic Rehabilitation Pillars

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• Our Case Management Approach

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• Our Rehabilitation Logic Model

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• Patient-centred Approach

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• The Legislative Framework

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• Strategic (Re) Focus

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• Strategic Policy Framework

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• The Coid Amendment Bill

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• Responsibilities of Stakeholders

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• Desired End State

MANDATE

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• Established in terms of Section 27(1)(c) of the

Constitution under the Bill of Rights to provide social security and appropriate social assistance

Constitutional Mandate

• To provide compensation for disablement caused by
• ccupational injuries or diseases sustained or

contracted by employees or for death resulting from such injuries or diseases and provide for matters connected therewith.

Legislative Mandate

• The Compensation Fund is established in terms of

Section 15 of the Compensation for Occupational Injuries and Diseases Act as amended

Statutory Establishment

VISION & MISSION

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Our Vision

To be a world-class provider of sustainable compensation for occupational injuries and diseases, rehabilitation and reintegration services

Our Mission

To provide efficient, quality, client-centric and accessible COID service To sustain financial viability To ensure an organization which takes care of the needs of its staff for effective service delivery

CORE BUSINESS UNITS

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Insurance Underwriting and Beneficiary Services COID 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 Aid Medical Benefits

• Medical Services ( Policy and Regulation services)
• Medical Claims (MSP Registrations, Medical Aid, Tariff Determinations, Electronic Invoice Switching)
• Managed Care (Pre-authorisations, Case Management)

Employee Reintegration Services Rehabilitation Services

• Vocational Rehabilitation Programmes
• Social Reintegration Programmes
• Provision of Assistive Technology

OUR STRATEGIC REHABILITATION PILLARS

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Medical Rehabilitation Vocational Rehabilitation Social Reintegration Provision of Assistive Technology

OUR CASE MANAGEMENT APPROACH

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Injury/ Occupational Disease Case Management Injury/ Disease Management Medical Treatment Medical Rehabilitation Rehabilitation Vocational Rehabilitation Social Reintegration Assistive Technology

Active Involvement of all Stakeholders at every stage of Care

Employers Trade Unions Employees Compensation Fund Medical Service Providers

OUR REHABILITATION LOGIC MODEL

Objective Strategy Output Outcome Performance Indicator

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Sustainable Social Security Managed Care Quality Rehabilitation Functional & Social Independence % Rehabilitated & Reintegrated

PATIENT-CENTRED APPROACH

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Employee (Beneficiary)

Employer Medical Service Provider The Fund OHNP/OMP

THE LEGISLATIVE FRAMEWORK

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Constitution (The Bill of Rights)

Section 27(1)(c): Everyone has the right to have access to social security, including, if they are unable to support themselves and their dependents, appropriate social assistance. Section 27(2): The state must take reasonable legislative and

• ther measures within its

available resources, to achieve the progressive realization of each of these rights Section 27(3): No one may be refused emergency medical treatment

Basic Conditions of Employment Act (BCEA 75 of 1997)

Section 22: Sick Leave – 36/12 cycle Section 23: Proof of Incapacity – Sick note if absent 2 days or more Section 24: Application to

• ccupational accidents or diseases –

Nullifies Sections 22 & 23 Section 25: Maternity Leave – 4/12 Section 26: Protection of employees before and after birth of a child- (1) No hazardous work; (2) Suitable or alternative employment on same terms for six (6) months post-natally if (a) Night Work and (b) Reasonably Practicable Section 83: Deeming of persons as employees Section 87(1)(b): Code of Good Practice on the Protection of Employees during Pregnancy and after the Birth of a Child.

THE LEGISLATIVE FRAMEWORK

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Labour Relations Act (LRA 66

• f 1995)

Section 185: Right to not be unfairly dismissed or subjected to Unfair Labour Practice Section 186(1): Meaning of Dismissal Section 186(2): Meaning of Unfair Labour Practice Section 187: Automatically Unfair Dismissals: (1)(e): Pregnancy, intended pregnancy or any reason related to pregnancy; (1)(f): race, gender, sex, ……disability,etc. Section 200A(4): Code of Good Practice on Who Is an Employee? Section 133: Dispute resolution through Commission (CCMA)

Employment Equity Act (EEA 55 of 1998)

Section 5: Employer to promote equal opportunity and eliminate unfair discrimination in all policies and practice Section 6 (1): Prohibition of unfair discrimination on the basis of disability Section 7(1): Prohibition of Medical testing Section 8: Prohibition of psychological testing Section 9: Employee includes applicant of employment Section 15: Affirmative action measures 2(a) identify and eliminate employment barriers 2(c) reasonable accommodation of designated groups (3) Preferential treatment of designated groups

THE LEGISLATIVE FRAMEWORK

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Occupational Health & Safety Act (OHSA 85 of 1993)

Section 3(1): Employer to ensure first aid treatment in case of injury or emergency Section 8(1): Employer to provide and maintain safe working environment Section 8(2)(b-d): Employer to identify, assess, evaluate and mitigate occupational hazards Section 14 (a): Responsibility of employee towards health & safety; (c) abide by lawful instruction; (e) immediate reporting of injuries Sections 24 & 25: Employer to ensure reporting of all work- related injuries and occupational diseases

Mine Health & Safety Act (MHSA 29 of 1996)

Section 5: Employer to maintain healthy and safe mine environment Section 11: Employer to assess and respond to risk Section 12: Employer to conduct

• ccupational hygiene measurements

Section 13: Employer to establish system of medical surveillance,; read in conjunction with Sections 14 – 20. Section 22: Employees’ duties for health and safety Section 23: Employees’ right to leave dangerous working place Section 54: Inspector’s power to deal with dangerous conditions Section 55: Inspector’s power to

• rder compliance

Section 86: Negligent act or omission

THE LEGISLATIVE FRAMEWORK

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Compensation for Occupational Injuries & Diseases Act (COIDA 130 of 1993)

Section 22: Right to Compensation; read in conjunction with Sections 38 – 41. Section 26: Special circumstances in which the Director-General may refuse award Section 28: Employee requiring constant help Section 29: Liability for payment of compensation Section 42: Employee to submit to medical examination Section 44: Prescription Section 45: Consideration of claim; read in conjunction with Sections 47 – 49. Section 56: Increased compensation due to negligence of employer

Compensation for Occupational Injuries & Diseases Act (CODA 130 of 1993- cont.)

Section 66: Presumption regarding cause of occupational disease; read in conjunction with Sections 65 & 68. Section 73: Medical expenses; read in conjunction with Sections 72 & 74. Section 75: Director-General to decide on need for, and nature and sufficiency of, medical aid. Section 76: Fees for medical aid; read in conjunction with Sections 77 & 78. Section 79: Consultation of representative medical authorities by Director-General. Section 85: Variation of tariff of assessment Section 90: Review of decisions by Director-General Section 91: Objections and appeal against decisions of Director-General

STRATEGIC (RE)FOCUS

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Grow Social Safety Net Improve Claims Turnaround Times Active Case Management Rehabilitation & RTW Disability Management

Disability Management Rehab & RTW Active Case Management Improve Claim TAT Grow Social Safety Net Current Focus Business Process Reengineering Future Focus

STRATEGIC POLICY FRAMEWORK

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Ensure enabling legislation

Driven by CF in accordance with its RR/RTW Policy Framework and COIDA Aligned to the vision and strategic objective of the Fund Responsive to the call of the NDP Vision 2030 to create an inclusive social protection system Developed in collaboration with all stakeholders With the ultimate aim of addressing the needs of the most vulnerable (injured/diseased employees) Outlines the rights, roles and responsibilities of all stakeholders Puts special emphasis on the need for health promotion and disease and injury prevention Encourages evidence-based methodologies and best practice across the board Based on a biopsychosocial approach which takes into account medical, psychological and social aspects

THE COID AMENDMENT BILL

To amend the Compensation for Occupational Injuries and Diseases Act, 130 of 1993 so as to substitute, insert, delete and repeal certain sections and definitions; to provide coverage for domestic employees, to provide for rehabilitation, re- integration and return to work of occupationally injured and diseased employees; to regulate the use of health care services; to provide for the reopening of claims; to provide for criminal and administrative penalties; to regulate compliance and enforcement, to provide for no fault based compensation system and to provide for matters connected therewith.

• The Preamble

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THE COID AMENDMENT BILL

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• by the insertion after the definition of “Disablement" of the following

definition: "‘Disability ' means for purposes of rehabilitation in terms of this Act a permanent long-term or recurring physical or mental disability which substantially limits the prospects of a person to obtain by virtue of any service employment or profession the means needed to enable that person to provide for maintenance;

Disability

• "‘Rehabilitation' means measures, services and facilities also in the form of

clinical, vocational and social rehabilitation provided for in Chapter VIIA of the Act provided with a view to the reintegration of employees exposed to an

• ccupational injury or disease back into work and to enable them to attain

and maintain where reasonable and practicable maximum independence, full physical, mental, social and vocational ability and full inclusion and participation in all aspects of life.

Rehabilitation

THE COID AMENDMENT BILL

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• 26 (b) if, in the opinion of the [Director -General] Commissioner the death [was

caused,] or the disablement was caused, prolonged or aggravated, by the [unreasonable refusal or wilful neglect of the] employee’s unreasonable refusing to submit to medical aid or rehabilitation programs in respect of any injury or disease, whether caused by the accident or existing before the

• accident. ".

Apportionment (Sect. 26)

• 42 (a) by the substitution for the heading of the following heading: "Employee

to submit to medical examination and rehabilitation; (b) by the insertion after subsection (1) of the following subsection: 1A An employee contemplated in subsection 1 shall if required to do so submit himself or herself to an examination for purposes of rehabilitation.

Independent Opinion (Sect. 42)

THE COID AMENDMENT BILL

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• 70A. (1) Subject to the provisions of this Act the Compensation Fund may

provide as the case may be facilities, services and benefits aimed at rehabilitating employees suffering from occupational injuries or diseases, to return to their work and to reduce any disability resulting from their injuries

• r diseases.

Rehabilitation (Chapter VIIA)

• 70A (2) The rehabilitation benefits provided in subsection 1 may consist of:
• (a)

clinical rehabilitation and the provision of assistive devices for the purpose of physical and psychological recovery of the employee and to reduce any disability resulting from an occupational injury or disease;

• (b)

vocational rehabilitation to assist an employee to maintain employment, obtain employment, retain or acquire vocational independence; and

• (c)

social rehabilitation to assist in restoring an employee's independence and social integration to the maximum extent practicable. "

Reintegration & RTW (Sect.16)

RESPONSIBILITIES OF THE FUND

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Claim Registration & Adjudication Early Identification of Eligible Cases Case Management Benefit Management Stakeholder Management & Collaborative Framework

RESPONSIBILITIES OF THE EMPLOYER

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Provide Safe Workplace Early Reporting of Injuries Institute RTW Programmes Provide Suitable Accommodation Maintain Occupational Hygiene & Medical Surveillance Systems

RESPONSIBILITIES OF THE REHABILITATION PROFESSIONAL

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Provide Cost- effective Rehabilitation Design Rehabilitation & RTW Plans Identify & Address RTW Barriers Advise Employers

• n Suitable

Accommodation Maintain Ethical, Evidence-based Practice

RESPONSIBILITIES OF THE OCCUPATIONAL HEALTH & MEDICINE PROFESSIONAL (OHNP/OMP)

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Protection & Promotion of Employee Health Assist in Establishment

• f Emergency

Preparedness Early Identification & Reporting of Deviation from Health Provide Expertise in Addressing Barriers in RTW Formulate Policies & Procedures for Effective RTW Maintain Evidence- based OH Programmes

DESIRED END STATE

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EXCEPTION

Contact Details

Dr Lucas Mosidi Compensation Fund Lucas.Mosidi@labour.gov.za Tel: (012) 406 5856/5 Cell: 076 448 7248

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Thank You Gracias Obrigado Ndaa..

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