Claims Guide
Claims Guide
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1. FEM

1.1. Who is FEM?

FEM is “THE FEDERATED EMPLOYERS MUTUAL ASSURANCE COMPANY (RF) PTY LTD”. FEM is licensed by the Department of Labour Compensation Fund to provide COIDA cover to employers in the Construction industry.

2. COIDA

2.1. What is COIDA?

COIDA is the Compensation for Occupational Injuries and Diseases Act (COIDA). The purpose of COIDA is to provide compensation for disablement caused by occupational injuries or diseases sustained or contracted by employees arising out of and in the course of their employment, or for death resulting from such injuries or diseases; and to provide for matters connected therewith. 

2.2. What is an Occupational Injury? (ACCIDENT)

An occupational injury is a personal injury sustained as a result of an accident during the course of employment. The accident must have a specific verifiable date, time and place. 

2.3. What is an occupational disease?

It is a disease arising out of and contracted in the course of an employee's employment and which is listed in Schedule 3 to the Act. 

2.4. Which Occupational Injuries (ACCIDENTS) must be reported?

All occupational injuries or alleged occupational injuries that entail medical expenses and/or absence from work for more than three days must be reported within seven days in the prescribed manner. 

The delay to report an accident or alleged accident is a criminal offence. The Commissioner may also impose a penalty on the employer which could be as much as the full cost of the claim. 

2.5. What are medical expenses?

Medical expenses are any reasonable costs incurred by or on behalf of an employee in respect of medical aid necessitated by an accident or disease occurring during the course of employment. 

2.6. What is Accident Frequency?

The accident frequency is the number of employees injured per hundred and is calculated as follows: 

Number of employee accidentsNumber of Employees × 100 = Accident Frequency 

For example with a total of 10 accidents and 100 employees your accident frequency will be 10%. 

2.7. What is Loss Ratio?

The loss ratio is the percentage of premium used to pay claims and is calculated as follows: 

Claims CostPremium × 100 = Loss Ratio 

For example with Claims costs of R10 and Premium paid of R100 your loss ratio would be 10%. 

2.8. What is a premium?

A premium is the percentage (based on the employers class of business) of the employers wage bill paid to the Compensation Fund / Mutual to cover their employees for COIDA. 

2.9. What is a class of business?

A class of business is the class of business the employers operates in as determined by the Compensation Fund according to the Compensation Fund schedule. This class determines the risk associated with that type of business and the rate is determined by the performance of this class. 

2.10. What is loading?

Loading is a penalty applied to the employer's Premium based on the poor claims record for the period under review. 

2.11. What is a rebate?

A rebate is a lump sum payment paid to the employers based on the good claims record for the period under review. 

2.12. What are the benefits under COIDA?

2.12.1. Reasonable Medical Expenses

All reasonable medical expenses for services provided by a registered medical service provider that are approved by the Compensation Fund and are in the opinion of the Compensation Fund / FEM essential.

2.12.2. Temporary Total Disablement (TTD)

  • 75% of an employee’s weekly earnings at the time of the accident – Section 47(1) (a), subject to the prescribed minimum and maximum amounts.
  • An employer is liable for TTD payments for the first three months from the date of accident – Section 47(3)(a).
  • Should the employee remain unfit for longer than three months, FEM will compensate the employee directly – Section 47(3)(b).

2.12.3. Permanent Disablement (PD)

  • Means Permanent Disablement for employment, permanent injury or serious disfigurement.
  • This is awarded to an employee for injuries ranging from the loss of a tooth, deafness, blindness, amputation of a limb, loss of mobility etc.
  • If the PD is assessed, more than 30% compensation will take the form of a monthly pension.
  • Where the degree of disablement is 30% or less, compensation will take the form of a lump sum based on 15 times the employee’s monthly earnings at the time of the accident.

2.12.4. Fatal

  • When an employee dies as a result of an injury on duty, his/her dependants may be entitled to compensation in terms of Section 54(1)(b) of the Act.
  • Compensation is based on the employee’s earnings at the time of his death and the relevant wage ceiling set by the Commissioner.
  • A widow will be entitled to 40% of the pension, she will receive it for life even if she remarries.
  • The widow also receives a lump sum equivalent to twice the deceased employee’s monthly pension.
  • The children receive a portion of the pension up to a maximum of 20% per child until the age of 18, or they die or marry before the age of 18. The total pension payable to all the children is a maximum of 60% of the pension with a maximum of 20% per child.

2.13. When do the benefits under COIDA occur?

  • The death of the employee.
  • The temporary total or temporary partial disablement of the employee.
  • The employee to be permanently disabled.
  • The employee to require medical aid.
  • The employee to contract an occupational disease.

2.14. Recording of Occupational injuries (ACCIDENTS) by the Commissioner

Upon receipt of the Employer's Report of an Occupational injury and a First Medical Report, the claim will be considered and if liability is accepted, notification will be addressed to the employer. The claim number allocated will appear on this notification. 

If liability cannot at that stage be accepted an acknowledgement will be addressed to the employer, providing the claim number allocated. 

N.B. EMPLOYERS ARE REQUESTED TO QUOTE THIS NUMBER IN ALL CORRESPONDENCE WITH THE FEDERATED EMPLOYER'S MUTUAL ASSURANCE COMPANY PROPRIETARY LIMITED (RF) RELATING TO OCCUPATIONAL INJURY. 

This will greatly facilitate the filing of correspondence and relevant documents on the appropriate file and will expedite finalisation of the claim.

The basic information to identify a claim is as follows:

  • The registered trade name and registration number as registered with FEM.
  • The full names and surname of the injured employee (not nicknames).
  • The employee's identity number/personnel number and date of birth.
  • The date the occupational injury was sustained.


The above mentioned information is captured on the computer and any discrepancies can result in duplication of claims, or that documents cannot be associated with an existing claim.

3. EMPLOYER AND EMPLOYEE

3.1. Who is an employer?

Any person including the State, who employs an employee. 

3.2. Who is an employee?

Any person who has entered into a contract of service with an employer. The service contract can be in writing, expressed or implied and applies to temporary, permanent and under aged workers and is defined in section 1 of the Act. 

This Act is not applicable to domestic employees employed as such in a private household. 

3.3. What is workers' compensation?

Workers' compensation is compensation and medical aid for workers who get injured or contract a disease while they are working. 

3.4. Which employers must register?

All employers in South Africa MUST register for COIDA. 

3.5. Which employees are covered?

All employees working within the South African borders or working overseas for a South African Employer are covered. 

3.6. Payment of Wages (TTD)

The employer is liable for the payment of compensation for the first three months from the date of the occupational injury.The compensation paid by the employer will be reimbursed by the FEM. 

If the accident resulted in the employee's death, documentary proof indicating the cause of death must be submitted without delay to your Regional office of The Federated Employers' Mutual Assurance Company Proprietary Limited(RF).

4. PROCEDURES

4.1. Procedure when reporting an Occupational Injury (ACCIDENT)

  1. Complete EMPLOYER'S REPORT in full.
  2. Sign and date form where indicated.
  3. Hand "Part B" to the injured employee before he goes for initial medical treatment and instruct him to hand "Part B" to the medical practitioner or hospital concerned. In serious cases "Part B" must be forwarded to the medical practitioner or hospital without delay.
  4. Complete the rest of Part A, pages 1 and 2.
  5. Forward completed form together with a First Medical Report (if available) to your Regional office of the Federated Employers Mutual Assurance Company LTD (FEM) with whom you have insured your liability in terms of the compensation for occupational injuries and diseases act, 1993.

4.2. Procedure when reporting an Occupational Disease

  1. An employer must within 14 days after he gained knowledge of an alleged occupational disease complete an Employer's Report of an Occupational Disease form1 and form2” and forward it to their Regional office of the Federated Employers Mutual Assurance Company LTD (FEM)
  2. The commencement of the disease shall be the date on which the doctor first diagnosed the illness.
  3. The occupational disease will be recorded in the same way as discussed above.

5. DISPATCH OF FURTHER DOCUMENTS

5.1. Occupational Injuries (ACCIDENTS)

When the First Medical Report was not posted together with the Employer's Report of an occupational injury, it must be obtained without delay and submitted to FEM. In cases of prolonged absence, a Progress Medical Report must be obtained monthly from the practitioner and submitted. When the employee resumes work, a Resumption Report must be completed and submitted to FEM together with the Final Medical Report. 

The Employer's Report of an Occupational Injury must not be kept in abeyance awaiting the medical report. 

The medical reports must not be kept in abeyance until the employee's condition has stabilized or when he has resumed work. 

5.2. Fatal Occupational Injuries (ACCIDENTS)

If the accident resulted in the employee's death, documentary proof indicating the cause of death must be submitted without delay to your Regional office of The Federated Employers' Mutual Assurance Company Proprietary Limited(RF).