Can I object to the insurance company's rejection of my pension fund claim after being medically boarded?

The long answer

The legal firm of Abrahams and Gross defines medical boarding as “the inability of an employee to work according to the requirements of their job as a result of ill-health or injury. This is also known as ‘no fault dismissals’ as the employee is not to blame for such a dismissal.”

I found it confusing that the company doctor and the insurance do not agree on whether you are able to work or not. When you submit a claim to the insurance (Rand Mutual Assurance, which handles insurance for mineworkers) your employer has to submit the claim, which must also be accompanied by the doctor’s first report. After the first report, the doctor must submit a further progress report, and then a final assessment by the doctor.

This is what Rand Mutual Assurance (RMA) says about the medical reports and their own final assessment of whether there is a permanent disability or not:

1. Medical reports – your first medical report from your treating doctor must be submitted with your original claim, however, additional medical reports are required during the course of your treatment so that we may track your progress, particularly in the case of Temporary Total Disablement (TTDs), also known as days off or temporary income replacement benefit.

2. Final assessment – this is the final document that will be submitted to RMA regarding your claim. You should not resume work unless the final assessment has been conducted by the treating doctor. This assessment allows RMA to assess if there is any permanent disablement in terms of COIDA. Should there be permanent disablement, you are entitled to compensation. If the injury is assessed at between 1% and 30% you will receive a lump sum payment. If the injury is assessed at between 31% and 100% you will be on a disability pension for life.

So, it seems that RMA still has the power to come to its own assessment of whether there is permanent disablement or not but, if you disagree, you can object to their assessment. They must then appoint a tribunal in terms of Section 91(2) of the Compensation for Occupational Injuries and Diseases Act 130 of 1993 (COIDA) to assess whether they were correct to decline your claim or not. 

In January 2022, Groundup published an article about a mineworker who was losing his hearing after working with very noisy machinery for a long time. This worker’s claim was declined by RMA because they said the worker had not proved that his hearing loss was caused by his work. He lodged an objection to RMA’s assessment and they appointed a tribunal, which upheld RMA’s assessment. The worker then took the matter to the Gauteng High Court, where two judges found that the worker was entitled to compensation as the RMA tribunal was required to prove that the worker’s hearing loss was not caused by his work, and they failed to prove it. In other words, it was not the worker who had to prove that his hearing loss was caused by his work, but RMA who had to prove that it was not caused by his work.

The judges found that the Tribunal did not properly assess the medical evidence that the worker presented, and so the court overturned the Tribunal’s decision and sent the matter back to the Tribunal to decide how much compensation the worker was owed.

So, in your case, if you – and the company doctor – disagree with the RMA assessment, you can lodge an objection in terms of s 91(1) Of COIDA within 180 days of the RMA assessment.

You can get a notice of objection form from RMA at any branch of RMA or through the call centre: 086 0222 132. You would need to fill in the form and send it back to RMA together with supporting documents like doctor’s or employer’s reports.

RMA must set up a meeting of an independent tribunal within three months. You can be at the meeting of the Tribunal or you can be represented by your union or lawyer. If the Tribunal upholds the RAM decision to decline your claim, you can, like the worker with hearing loss, take the case to the High Court. 

With regard to the second part of your question – about whether you can claim your pension fund now that you are not receiving wages: As you have been medically boarded, which is known as a “no fault dismissal”, you should certainly be able to claim your pension or provident fund.

These are the documents you need to claim from the Mineworkers Provident Fund: 

1. Withdrawal (Retirement, Disability & Terminally ill) claim form signed by the member and two employer authorised signatories, AND stamped by the mine;

2. Banking details (copy of a bank statement stamped by the bank);

3. Certified copy of Identity Document;

4. Payslip.

For claims, you need to contact the Human Resources office at the mine.

For general enquiries: 

Email: clientsservices@mineworkers.co.za

Tel: +27 (0) 10 100 3001

Wishing you the best,
Athalie