What is an RAF 4 serious injury assessment?

Most people bringing a Road Accident Fund claim think the fight is about how much the injury is worth. For general damages it is not, at least not first. The fight is about whether you are allowed to claim them at all.

That question is decided by a single form and by an administrative process most claimants have never heard of, and it is where a great many claims quietly lose their largest component.

Why the assessment exists

Section 17(1A) of the Road Accident Fund Act 56 of 1996 provides that the Fund is liable for compensation for non-pecuniary loss, meaning general damages for pain and suffering, disfigurement and loss of amenities of life, only in respect of a serious injury, assessed in the prescribed manner.

This was introduced to remove the large volume of minor-injury general damages claims from the system. Its practical effect is a gate: pass it and general damages are in play; fail it and they are gone entirely, however genuinely you suffered.

The gate applies only to general damages. Everything else in your claim is unaffected:

• past and future medical expenses
• past and future loss of earnings or earning capacity
• loss of support in a fatal claim
• funeral expenses

Those heads do not depend on the injury being serious. Our guide on what a RAF claim is worth sets out the heads, and the RAF claim range indicator gives the shape of a claim.

So a claimant who fails the serious injury assessment has not lost the claim. They have lost one head of it, which is often the one they were most focused on.

The RAF 4 form

The assessment is recorded on the prescribed RAF 4 serious injury assessment report.

It must be completed by a medical practitioner registered under the Health Professions Act, and the Regulations require the assessment to be done by a practitioner who has completed the prescribed training in the method the Regulations prescribe, which is based on the AMA Guides to the Evaluation of Permanent Impairment, sixth edition.

That detail matters more than it sounds. A report completed by a practitioner who is not trained in that method, or which does not apply it properly, is vulnerable, and the Fund rejects reports on exactly that basis. Your own GP, however well they know you, is usually not the right person.

Practically, the assessment is done once your condition has stabilised. Assessing an injury while it is still improving produces a figure that does not reflect the permanent position, which is one reason RAF claims take as long as they do. Our guide on how long a RAF claim takes explains the timeline.

The two routes through the gate

There are two, and only one of them is arithmetic.

The 30% threshold

The practitioner calculates whole person impairment using the prescribed method. If the injury results in 30% or more WPI, it is serious. That is the end of the enquiry.

Thirty per cent is a high bar. It is not reached by a broken arm that healed, or by soft tissue injuries, or by most fractures that united well. It tends to be reached by amputations, significant brain injury, spinal cord injury, and multiple severe injuries in combination.

Most claimants do not reach it, which is why the second route is where the real work happens.

The narrative test

Where the impairment is below 30%, the practitioner must apply the narrative test. An injury is serious if it:

• resulted in a serious long-term impairment or loss of a body function, or
• constitutes permanent serious disfigurement, or
• resulted in severe long-term mental or severe long-term behavioural disturbance or disorder, or
• resulted in loss of a foetus.

This is a qualitative judgement rather than a calculation, and it is where thoughtful reporting changes outcomes. A 12% impairment in a person whose work requires them to stand all day, or whose hand injury ended a trade, is a different case from the same figure in a person whose work is unaffected.

The narrative test is about the effect of the injury on this person's life. A report that recites percentages and says nothing about function is a weak report even when the underlying injury is severe.

The Fund decides, not the court

This is the single most misunderstood feature of the process, and it has ended a great many claims.

Following Road Accident Fund v Duma and the cases that have followed it, the position is settled: whether an injury is serious is determined by the Fund in the first instance, on the RAF 4 report submitted to it. A court hearing the damages action cannot decide that question for itself. If the Fund has not accepted the injury as serious, the court has no general damages claim in front of it to adjudicate.

That is why the procedural steps below matter as much as the medicine.

Submit the RAF 4 with the claim.

The Fund considers it. It may accept the assessment, reject it, or direct that the claimant submit to a further assessment by a practitioner it designates.

If it accepts, general damages are in the claim and the argument moves on to quantum.

If it rejects, you are into the dispute procedure, and there is a deadline.

The 90 days

Where the Fund rejects the assessment, or where either side disputes a further assessment it required, the disputing party must, within 90 days of being informed, notify the registrar of the Health Professions Council of South Africa that the rejection or assessment is being disputed.

The matter then goes to an appeal tribunal of independent medical practitioners appointed by the HPCSA, which determines the question. Its determination is final and binding on the parties, subject only to review.

Three things follow, and they are the practical core of this guide.

Diarise the date the moment a rejection arrives. Ninety days sounds generous and is not, because obtaining further medical evidence takes longer than people expect.

Do not treat a rejection as the end. It is a step in a process with a defined remedy, and tribunals do overturn rejections.

Do not ask the trial court to decide it instead. That route is closed, and a claimant who spends two years preparing a damages action on general damages that were never accepted as serious has wasted the time.

Where the Fund simply does not respond at all, neither accepting nor rejecting, the position has generated its own litigation. The practical answer is to press for a decision, in writing and on the record, rather than to assume that silence is acceptance or to proceed as though the gate has been passed.

What makes a strong assessment

Get the right practitioner. One trained in the prescribed method, who does these assessments regularly and whose reports the Fund is used to seeing.

Wait until the position is stable, unless there is a reason not to, because an assessment done too early understates the permanent effect.

Bring the whole picture. Hospital records, operation notes, radiology, physiotherapy and psychology reports, and the specialists who treated you.

Speak to the function, not just the injury. What you could do before, what you cannot do now, what work you can no longer perform, what you have given up. This is the material the narrative test runs on and claimants consistently underplay it.

Do not forget psychological sequelae. Severe long-term mental or behavioural disturbance is one of the four narrative categories in its own right, and post-traumatic symptoms after a serious collision are common and under-reported.

Keep the appointment where the Fund requires its own assessment. Failing to attend is unhelpful and entirely avoidable.

Worked example

This example is illustrative. A delivery driver is hit at an intersection. He suffers a fractured ankle requiring internal fixation, and he develops persistent pain and a limp. He also develops anxiety about driving and has not returned to work eighteen months later.

The RAF 4 is completed by a practitioner trained in the prescribed method, who assesses whole person impairment at 14%. That is well below 30%, so the 30% route fails.

The narrative test is then applied. The report describes a serious long-term impairment of a body function: he cannot stand or walk for the periods his work required, the limp is permanent, and the ankle will require further surgery. A separate psychological report addresses the driving anxiety.

The Fund rejects the assessment, saying the injury does not meet the narrative test.

He has 90 days from being informed to notify the HPCSA registrar that he disputes the rejection. He does so, and the appeal tribunal considers the reports and determines that the injury is serious.

Two things are worth noticing about that sequence.

His claim for loss of earnings was never dependent on any of it. Eighteen months out of work, and a reduced earning capacity going forward, were claimable throughout, as were his medical expenses. What was at stake in the assessment was general damages alone.

And had he let the 90 days pass, the tribunal route would have closed, and no court could have opened it for him.