claims processing value chain - road accident fund. raf_claimslitigation... · judgement monitoring...

1. Claims Origination 2. Claims Determination 3. Claims Litigation 4. Claims Finalisation

Claims Processing Value Chain

1.1. Hospital service centres

1.1. Community service centres

1.2. Document management *

1.3. Registration, validation & verification

1.4. Mobile RAF

2.1. Medical

2.2. Represented claims

2.3. Direct claims

3.1. Summons administration

3.3. Internal law department (ILD)

3.4. Magistrate, high & district court litigation

3.5. Panel attorney management

4.1. Capital payment

4.2. Legal cost validation

4.3. Legal cost payment

4.4. Writs payment

3.6. Judgement monitoring

4.5. Claims file closure

5. Post Claims Settlement

5.1. Post claims management

1.5. Merits

3.2. Writs management

2.4. Supplier claims

Version 20, 06 June 2013* Report to Correspondence Manager

Symbols and Abbreviations

On page reference

Off page reference

Action

Process

Decision

Symbols Abbreviations

· AMA - American Medical Association· BI - Body Identification· BIF - Banking Indemnity Form· CAFS – Central Archiving Filing System· CC - Compensation Commissioner· CLS - Legal and Compliance· CO - Claims Officer· COO - Chief Operations Officer· CSC - Customer Service Consultant/Centre· DM - Document Management· DOA - Date of Accident· DoB - Date of Birth· EA - Expenditure Authorisation· EIL - Employer Individually Liable· ES - Executive Summary· GD- General Damages· GM - General Manager· HCM - Hospital Case Manager· HPCSA - Health Professions Council Of South

Africa· HSC - Hospital Service Consultant/Centre· ICT - Information Communication

Technology· ID - Identity Document· ILD - Internal Law Department· IT - Information Technology· LCO - Legal Cost Officer· LoE - Loss of Earnings

· LoS - Loss of Support· MMI - Maximum Medical Improvement· MVA - Motor Vehicle Accident· NB - Nota Bene (Important)· OAR - Official Accident Report· PA - Panel Attorney· POP - Patient Outreach Program· RAF - Road Accident Fund· RAF 1 - Road Accident Fund Form 1· RAF 2 - Road Accident Fund Form 2· RAF 3 - Road Accident Fund Form 3· RAF 4 - Road Accident Fund Form 4· RAF 5 - Road Accident Fund Form 5· RSA - Republic of South Africa· SAPS - South African Police Service· SMR - Statutory Medical Report· SMS – Summons Management System· SOP - Standard Operating Procedure· U number - Undertakings Number· U system - Undertakings System· UBC - Unabridged Birth Certificate· UO - Undertakings Officer· V&V - Validation and Verification· WCC - Workmen's Compensation Commission

System intervention





1.2. Document management


1.4. Mobile RAF

2.1. Medical


2.3. Direct claims








4.4. Writs payment





1.5. Merits



3.1.1. Summons unit process (Part 1 of 3)

Administrative assistant

Summons administration

officer


officer


officer


officer



officer

Summons served via sheriff/mailroom/

fax

Date stamp check claim number on

“Claims View”

The claim is traced by using the claim number, link number and/or claimant ID number

The system does warn the user if there are summonses already linked to a particular claim

Can claim be located physically

or at CAFS?Yes

File not found process

A

B

File in another region?

No

Yes

Write claim number on summons pack and

register summons on the Summons

Management System

Capture summons on distribution spread sheet

Place a note on Claims View and

Summons Management

System

Scan documents and send via docex to relevant region

B

No


Summons team leader

Summons senior officer



officer


officer


Senior has rights to rectify appointment on the system process

Accept summons from summons administrator

Is summons from

High Court

Check if there are linked files

Are there linked files?

Did system allocate same

Panel Attorney?

No

Is attorney still on

the Panel?

No No

Did system allocate matter to a local Panel

Attorney?

A

E

DIs court outside

15km radius from the Fund offices?

Yes

File confirmation spread sheet

End

No

H

H

Forward summons to ILD team leader

for defending

Distribute summons to relevant unit

Indicate intention to defend on

system

Is the summons for a supplier

claim?

Is court within 15km radius

from the Fund offices?

No

Yes

H

No

E

No

Yes Yes

Yes

YesD

Yes

Senior has rights to rectify appointment on the system process

Yes


D


officer


officer Summons administration

officer


officer


officer


officer


officer


officer


officer


officer


officer



officer


E

EndFile confirmationYes

Follow up telephonically and if

needs be, re-send instruction letter

NoYes

No

3.1.1.3. Follow up to check if matter

has been defended

Send confirmation batch for scanning

Raise matter with unit Senior

Determine whether an instruction was

sent to an incorrect attorney

Yes

Follow up telephonically and if needs be, re-send

withdrawal letter

No

Did Panel Attorney confirm receipt within 24

hours?

No

YesFile confirmation (of

withdrawal)

Print letter of instruction for

correctly appointed Panel Attorney

At end of day, send confirmation batch for

scanningG

G

G

Print instruction letter to be sent to

Panel Attorney

Was an instruction sent to an incorrect

attorney?

YesSend withdrawal

instruction

D

No

Did Panel Attorney confirm receipt in writing within 24 hours?



Send instruction letter via email

(with read receipt) or facsimile. Wait

for attorney to confirm receipt of

instructions

Override system appointment and

put notes on ‘Claims View’ and Summons

Management System

DD







1.4. Mobile RAF

2.1. Medical


2.3. Direct claims








4.4. Writs payment





1.5. Merits



3.2.1. Writ management process



Administra-tive

assistantAdministrative

assistant

Writ officer

Writ officer

Writ officerAdministrative assistant

Writ senior

Writ officer

Writ officer

Writ officerWrit officer Writ officer Writ officer

Writ officer

Writ officer Writ officer

A

Receive writs from sheriff

Acknowledge receipt (register) and stamp within

10 minutes

AIs the writ

valid?

Record on template and escalate to

senior

No

Record in writs register

Separate writs according to capital, legal cost and other

branch

Conduct writs assessment within

20 minutes of receipt

- Verify if it is a registered claim- Verify not a duplicate

End

Compare writ and payment checklist

to verify information is

complete

Yes

Communicate the invalid writ to

Sheriff

Capture writ in the writ system and

stamp as captured

Receive proof of payment from Writ

Payment unit

Prepare writs summary and

record assessed writ on excel register

and intranet

Refer assessed writ to senior for

review

Senior accept?

Yes

Refer writ to Forensics for investigation

No

End

EndPrepare trigger

document

Send file to Writ Payment unit for

payment

Is all the information needed to

prepare the trigger

available?

Scan writ and send to the relevant unit to get information

within 4 hours

Did you receive information?

No

Yes

BYes

Record on register and escalate to

senior

No

C

C

B

Together with senior, follow up with the relevant

unit







1.4. Mobile RAF

2.1. Medical


2.3. Direct claims








4.4. Writs payment





1.5. Merits



3.3.1. Magistrate court process (Part 1 of 2)

ILD officer ILD officerILD officer

ILD officer

ILD officer

ILD officer

ILD officer ILD officer ILD officer ILD officer

ILD officer

ILD officer

Has trial date been issued?

Yes

3.3.1.2. Prepare for

pre-trial

3.3.1.1. Pleadings draft

processesPrepare an offer

Has an offer been

accepted?

No

The file has to be pro-actively

prepared for trial, not only get

prepared when the matter is classified

as litigious

Load offer on system & generate update SMS to claimant/

representative

Make offer to plaintiff attorney

Accept offer on system, generate acceptance sms & request payment

Prepare file & deliver to capital payment unit for

settle3.1. Magistrate court

process (1/3)ment

End

A

A

Receive files from Summons

Administration

3.3.1.2. Prepare for

pre-trial

B

Reject and revise offer

C

Enter appearance to defend

Request further particulars for the

purpose of plea

No

Yes

C

3.3.1. Magistrate court process (Part 2 of 2)

ILD officer ILD officer ILD officer ILD officer ILD officer

ILD officer

ILD officer

ILD officer

ILD officer ILD officer ILD officer

ILD officer

Try to settle with the plaintiff before the matter goes to

trial

Attend to Pre-trials where the plaintiff attorney may

want to set the matter down for hearing

Officer continues to make an offer

before trial date

Determine contingency deductions to be applied

(apportionment and risk)

Consider any prior payments/interim payments/WCC/

social grants

BD

Prepare offer Make offer to

plaintiff attorneyD

Load offer on system & generate

update sms to claimant/

representative

No

No

Reject and revise offer

Is the offer accepted?

Prepare file & deliver to Capital payment unit for

settlement

End

Rule 18 tender or settlement agreement is drafted then signed by

both parties

Yes

3.3.1.3. A Panel Attorney

is appointedEnd

Are there any contentious

issues?Yes

Accept offer on system, generate

acceptance SMS & request payment

E

E

D

3.3.1.1. Pleadings draft processes

ILD officerILD officer ILD officer ILD officer

ILD officer

ILD officer ILD officer

Senior ILD officer

ILD officer DriverDriver Driver

Driver

Driver ILD officer

Receive notification from claims officer/

summons administrator to draft pleadings

Request all files from claims officers

Have all the files been received?

Notify claims officer and request

outstanding files

No

Peruse file and summons

documentationYes

Finalise notice of intention (10 days) and pleading (20

days) and submit to senior for review

Does the senior approve?

AYes

Suggest amendments to be

made

No

A Senior to sign off

Prepare 3 copies to be submitted to

Plaintiff Attorney, Court, and the Fund

Does plaintiff attorney accept?

Get all 3 copies stamped by plaintiff

attorneyYes

Return to RAF for amendments and

resubmission

No

B

B

Deliver stamped copy by plaintiff

attorney to court for

acknowledgement

Get all 3 copies stamped by court

C

CDriver to return stamped copy to

RAF

Place copy on file and prepare file to be returned to CO

for settlement

End

Draft notice of intention and

pleadings

Driver to serve all copies to plaintiff

attorney for acknowledgement







1.4. Mobile RAF

2.1. Medical


2.3. Direct claims








4.4. Writs payment





1.5. Merits



3.4.1. High court litigation process (Part 1 of 5)

Administrative assistant Administrative assistant Litigation officer Litigation officer

Litigation officer

Litigation officer

Litigation officer

Litigation officer

Litigation officer

Litigation officer

Litigation officerLitigation officer

A

Share all the relevant

information with the Panel Attorney

Receive notification from the Summons Department that

the case will be defended by the Panel Attorney

Team Leader confirms receipt of notification and

allocates the file accordingly within his/her team

Trace the location of the file (follow up with ‘Claims Determination’

& CAFS)

Is the file located?

3.1.1. Request a copy of the file

contents from the Plaintiff attorney

No

Send a letter to the plaintiff and panel attorneys to

provide the contact details of the new officer within 5 days

of instruction

Yes A

Does the plaintiff attorney

want to discover?

Are there outstanding

docs?Yes

Panel attorney to provide

recommendations on merits

Yes B

Have merits been settled?

No

No

Yes

No

Has the quantum been determined?

Record quantum determined by the Panel

AttorneyYes

Sense-check the quantum assessment with respect

to the case and its supporting docs.

No

D3.1.4. Merits investigation

follow up

3.1.5. Quantum

Assessment follow up

C

B

Try settle the matter

If matter cant be settled, continue with process

C




Litigation officer


Litigation officer

DIs the Panel

Attorney's offer reasonable?

Has the offer been made?

Yes Has the offer

been accepted?Yes

Request the Panel Attorney to forward the

signed acceptance letter for payment

processing

Yes

FDiscuss the offer

made with the line manager/colleagues

No

Enquire why an offer has not been

made

No

Is the response acceptable?

Diarise and follow up within 3 days

Yes

X

G

No

Make an offer and communicate this

with panel attorney

No

E

D

Is the capital payment request within mandate?

Print expenditure authorisation

Yes

Prepare an executive summary

for approval

No

Send the executive summary to senior

for review and approval

Does the line manager think the

offer is reasonable?

Yes

K

No

J

X



Litigation officer

Litigation officer

Litigation officer


Litigation officer

Litigation officer

F Does the senior accept?

Revise the executive summary

No

Send expenditure authorization and supporting doc. To

Capital Payment unit

Yes

Complete closure report, SLA breach report for

Panel Attorney management and

judgement monitoring

Send to senior for approval

Is the report satifactory?

Revert back to the officer

No

Revise the closure report

Forward the legal bills to the Legal

Costs Validation unit

End

Yes

Send executive summary for

approvalF

J

Forward closure report, SLA breach

report to Panel Attorney

management and judgement monitoring



Litigation officer

Litigation officer Litigation officer Litigation officer

Litigation officer

Litigation officerLitigation officerLitigation officer

Litigation officer

Revert to the Panel Attorney, discuss

the offer made and suggest changes

Does the Panel Attorney agree?

Diarise to follow up with Panel Attorney

within 2 daysYes

Is the offer too low or too high?

No

Analyse the scope to check if the offer

can be increasedToo lowToo high

Enquire reasons why an offer was

not accepted

Did the plaintiff deem the offer to

be too low?

Review the case and its supporting doc.

Yes Is there scope to

increase the offer?

Discuss the matter with the line

manager/colleaguesYes

Does the line manager agree?

Yes

No No

Assist in formulating the litigation

strategy

Are there any litigious disputes?

No

No

Revert back to Panel Attorney and

discuss the strategy.

Diarise and follow up before trial

2 weeks before trail: follow up with the Panel Attorney

on the matter and share newly discovered

information (if any) and trial matters

3.4.1. Escalate the litigious dispute to

senior

Yes L

K D

G

M

K

KKEnd

K


Phase

Litigation officer

Litigation officer

Litigation officer


Litigation officer

Litigation officer

M

Pre-prepare executive summary should the matter

go against the fund (i.e. w.r.t. mandate)

Post trail: enquire about trail outcomes and/or

out of court settlements

Are the matters resolved?

Request the Panel attorney to furnish all

required docs. To effect payment within 3 days

No

3.5.1. Matter goes to trial

Court order received for payment?

Yes NYes

N

Request capital payment to make

the payment

Liaise with the Panel AttorneyL

E

O

Is the settled amount above

approved mandate?

No

Prepare an ES for approval

Is the ES approved?

Yes RYes

R

K

K

No

No

3.1.4. Merits Investigation Follow Up

Litigation officer

Litigation officer

Litigation officer

Litigation officer

Litigation officerLitigation officerLitigation officer

Check if the report(s) has/have been received post

assessment

Have the reports been

received?

Forward reports to the Panel Attorney

Yes

Diarise Merit assessment follow up

with the Panel Attorney within a week

No

Enquire why merits were not settled

Does the panel attorney need to appoint an

expert?

Yes

Escalate the matter with the senior

officer

End

3.4.1.2. Senior follows up

with the Panel Attorney

No

Did the panel attorney provide an

acceptable response on what is holding up merits?

Yes

Liaise with senior and approve

appointment of experts

Inform panel attorney and diarise matter for follow up

P

P

No

End

N

If Panel Attorney doesn’t comply, request merits to conduct merits assessment

3.4.1.5. Quantum assessment follow up process

Litigation officer

Litigation officer Litigation officerLitigation officer

Litigation officer

Litigation officer

Litigation officer

Litigation officer

Are there any outstanding reports

(e.g. actuarial reports)?

Have these reports been requested?

YesHave the experts

been paid?Yes

3.1.5.1. Follow up with capital

payment and experts/service

provider

Yes

Approve appointment of

expert

No No

Enquire what is holding up quantum

determination

No

Is the response

acceptable?

3.1.5.4. Senior follows up with the

Panel Attorney

No

Diarise for follow up within a week

Yes

N

3.1.5.5. Expert payment process

C

C

O

Check if the report(s) has/have been received post

assessment

Have the reports been

received?

Forward reports to the Panel Attorney

N

Yes

No

Q

Q

Diarise Merit assessment follow up

with the Panel Attorney within a week

B

End

End

If panel attorney has not appointed an expert, appoint expert

3.4.1.5.4. Expert payment process

Senior officer Senior officerSenior officer Senior officer

Senior officer

Senior officer

Prepare an executive summary to address

the situation

Is the expenditure within mandate?

Forward to senior for approval

Yes

Executive summary/ expenditure authorization to be forwarded to finance

for payment

Diarise and follow up within 3 days

Forward executive summary to persons

with mandate

No

Is the executive summary approved?

Yes

Revise the executive summary/expenditure

authorization

No

Has payment been made?

EndYes

No







1.4. Mobile RAF

2.1. Medical


2.3. Direct claims








4.4. Writs payment





1.5. Merits



3.5.1. Panel attorney management (Part 1 of 2)


Panel attorney management officer

Panel attorney management

officer



officer



officer

Panel attorney management senior



officer


senior

Receive complaints and/or breach notices with regards

to attorney performance

Analyse breach as presented in the summary and/or breach report and/

or SLA

Is the complaint a minor breach?

Engage in conflict resolution with the

Panel AttorneyYes

Is the conflict/complaint resolved?

AYes

B

No

B

No

ADoes the report reflect the resolved issues and

is it satisfactory?

Send to the assistant for filling

Yes

Highlight the report’s shortcomings and revert

to the offer

No

Revise the report

End

BDiscuss the

recommended actions with senior

Are the recommended actions justified?

Yes

Discuss with officer and recommend justified penalty

No

Revise the recommendation

D

D

E

F

F

Compile a report to this effect and forward to

senior for review

Analyse and recommend what financial penalties or charges may be levied due to poor service delivery to

the office of the COO

3.5.1. Panel attorney management (Part 2 of 2)


officer




Sign off on recommendation as per delegation of

authority with respect to level of penalty

Is the reviewer mandated to sign

off penalty?

Escalate to relevant departments (IT if the Panel

Attorney has been suspended), office of the general manager

and the COO

Yes Liaise with relevant

Panel Attorney about penalty

End

Escalate recommendation to line manager for review

and/or sign off

No

E

3.5.2. Regular monitoring of litigation services by Panel Attorneys

Administrative assistantAdministrative

assistant



officer


officer


officer



officer


officer


officer


officerPanel attorney

management officer


officer

Receive closure reports from the magistrate and/or high

court units. Receive Quarterly reports from Panel Attorney

Assistant allocates the closure report to the

relevant officer/monitor

Officer updates the Panel Attorney SharePoint (with the service rating from the closure report and comments from the

Litigation Officer)

End

ACompile report for

senior to review and approve intervention

Senior agrees with recommended intervention?

Inform relevant officials in the office of the line manager, COO and General Manager

Yes

Review service ratings for each firm quarterly

Is there a need to liaise with

the firm?

No

AYes

End

No

Together with the manager, arrange to

meet the Firm’s directors and/or representatives

B

BHave raised matters been acknowledged

and accepted?

Escalate the matter to the Office of the COO (and the

GM) via an ES

No

End

Did the Panel Attorney commit to resolving the

issue(s)?

Yes

C

No

C

Through an ES, update the relevant

officesYes

Follow up with the Panel Attorney (within the agreed timeframe)

D

Does the COO approve?

Suspend/penalise/fine Panel Attorney

Yes

E

No

E

Panel Attorney resolved issues

Yes

C

No

Highlight service issues that have

been raised by the Fund

Finalise report and send to the office of

the COO

End







1.4. Mobile RAF

2.1. Medical


2.3. Direct claims








4.4. Writs payment





1.5. Merits



3.6.1. Judgement monitoring

Judgement monitoring officer

Judgement monitoring team leader

Judgement monitoring team leader

Judgement monitoring

officer


officer


officerJudgement monitoring officer



officerJudgement monitoring

officer




officer

Propose cases to be analysed for the

month to the senior and/or team leader

A

Judgement monitoring officer analyses the cases as per set criteria

Team leader approves cases to be analysed?

AYesSelect judgements to be

monitored

At the discretion of the Unit senior, the cases which could be investigated may be based on the following: - Capital paid - Elapsed time between merits determination and capital payment request - etc.

Senior or team leader reviews cases

to be analysed for the month

Senior and team leader revise list

No

The evaluation criteria will be formulated and finalised when the SOPs are developed

Report on shortcomings and achievements for each case through a report.

Furthermore, highlight lessons or procedural suggestions which should be

implemented going forward

Forward the ES to the senior for

review and approval

Does the report accurately reflect the situation?

Forward the report to the team leader

for review and approval

Yes

Revert to the officer and highlight shortcomings of

the report

No

B

B

Is the report professionally

drafted for publication?

C

Revert to the senior for alterations

No

C

Forward a copy to line management (i.e. Senior Claims Manager and GM)

YesCan the report be forwarded to CLS and be published?

Revert to the senior and/or team leader and raise

concerns

No

C

Forward the report to CLS for review and publication

Yes End

Frequently asked questions in litigation

What should happen to files that have been summonsed post repudiated?Summons served after repudiation in merits should be sent to litigation not determination.

Should summons be defended by other regions (i.e. a Pretoria summons is defended by East London)Defend then forward the summons.

What should happen to supplier claims that have been litigated (summons served)?Litigated supplier claims should be sent to ILD.

Should a branch process a summons even if it is not for that branch in order to eliminate delays in transferring of summons?Summons received for other regions should be defended first before being sent to the correct region.

Do we defend all summonses?Yes, regions should defend all summonses.

claims processing value chain - road accident fund. raf_claimslitigation... · judgement monitoring...

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