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Workers Compensation Entitlements Explained – Medical, Hospital, and Rehabilitation Expenses

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Workers Compensation Entitlements Explained – Medical, Hospital, and Rehabilitation Expenses

A worker who suffers an injury arising out of or in the course of employment may be entitled to medical, hospital, and rehabilitation expenses where the medical treatment:

  • Is of a kind covered under the Workers Compensation Act such as medical or related treatment, ambulance service, hospital treatment (whether public or private), and workplace rehabilitation services; and
  • Takes place while the worker is entitled to receive compensation for medical, hospital and rehabilitation services; and
  • Is reasonably necessary because of the injury; and
  • Is pre-approved by the insurer (unless the treatment or service is exempt from pre-approval as discussed below).

 

Medical or Related Treatment

Medical related treatment can include:

  • treatment by medical practitioners, physiotherapists, psychologists, counsellors, exercise physiologists, and/or other allied health practitioners;
  • provision of artificial aids such as crutches, joint replacement etc;
  • domestic assistance services;
  • nursing, medical and medicine supplies (provided outside of hospital treatment); and
  • modifications to your home or vehicle.

The insurer will only pay expenses for treatment or services which are reasonably necessary as a result of your injury, so you should ensure you have the insurer’s approval of the requested treatment prior to receiving it.

However, some treatments don’t require pre-approval in order for you to claim expenses. These include but are not limited to:

  • Initial treatment (any treatment within 48 hours of the injury happening);
  • Appointments with your nominated treating doctor (NTD) in relation to your injury;
  • Treatment during an appointment for the injury provided by your nominated treating doctor within one month of the injury;
  • Any services for the injury that are provided in the emergency department of a public hospital; and
  • Some treatments with allied health professionals (but it is best to speak with your claims manager first).

 

Workplace Rehabilitation Services

Workplace rehabilitation services can include:

  • Support for an injured worker to recover at work or return to work;
  • The provision of vocational, functional and workplaces assessments;
  • Support in identifying suitable work;
  • Re-training and placement in employment (subject to cost limits).

 

Domestic Assistance

Domestic assistance can include tasks around the home that you are no longer able to carry out due to pain or injuries such as household cleaning, laundry, lawn and garden care.

In order to claim for domestic assistance an injured worker must:

  • Be certified by a medical practitioner that domestic assistance is reasonably necessary based on a functional assessment and that the need for domestic assistance arises from the injury;
  • Establish that the worker performed the domestic task prior to the injury;
  • Have 15% whole person impairment or more or the assistance is temporary (up to six hours per week for a total period of three months).

Frequently Asked Questions:

What is reasonably necessary?

The phrase ‘reasonably necessary’ is the test used by the insurer when determining whether they are responsible for payment of a requested treatment expense.

When deciding whether the treatment is ‘reasonably necessary’, the insurer considers things like the following questions:

  • Is the treatment required as a result of the injury?
  • Is the treatment likely to alleviate pain or symptoms of the injury?
  • Is the treatment reasonably necessary for this particular person (noting that what may be reasonably necessary for one person, may not be reasonably necessary for a different person requesting the same treatment)?
  • Is the requested treatment appropriate?
  • Is their alternative treatment options available that might be more beneficial or at least worth trying in the first instance?
  • Does the evidence provided by the medical professionals support this request, and is this an accepted form of treatment in the medical profession?
  • Is the cost of the treatment appropriate?

As you can see the reasonably necessary test is not a simple process which means that sometimes the insurer will take some time to consider the request and provide an outcome.

 

How long does the insurer have to consider the request and make a decision?

Insurers are to determine treatment approval as soon as possible after receiving a request. All treatment requests must be determined within 21 days of receipt.

In some cases, an insurer will deny a treatment request whilst they wait for further evidence such as a report from your treating doctor or an independent medical doctor.

How long are my medical, hospital, and rehabilitation expenses covered for?

You may only claim for the cost of medical and related treatment, hospital treatment and rehabilitation services during a specific compensation entitlement period and this period depends on whether or not your injury has resulted in an assessed degree of permanent impairment.

Workers with no permanent impairment or a permanent impairment assessed as 10 per cent or less can claim expenses for treatment or services provided:

  • for two years after weekly payments stop being payable, or
  • for two years from the date of claim if no weekly payments made.

Workers with a degree of permanent impairment assessed as more than 10 per cent but not more than 20 per cent can claim expenses for treatment or services provided:

  • for five years after weekly payments stop being payable, or
  • for five years from the date of claim if no weekly payments made.

Workers with high needs can claim medical and related expenses for life. A worker with high needs is a worker:

  • with a permanent impairment assessed as more than 20 per cent; or
  • an assessment of the degree of permanent impairment is pending and has not been made because an approved medical specialist has declined to make the assessment on the basis that maximum medical improvement has not been reached and the degree of permanent impairment is not fully ascertainable; or
  • the insurer is satisfied that the degree of permanent impairment is likely to be more than 20 per cent.

 

What about the cost of travelling to all of the appointments and to the pharmacy?

You are entitled to claim reimbursement for travel to and from appointments relating to treatment of your workplace injury, including travel to and from pharmacy.

If you drive in your own car, you are entitled to claim $0.55 per kilometre.

If you travel via public transport, you can submit your receipts to the insurer for reimbursement.

Some insurers require travel reimbursement claims to be set out on a particular form so it is best to chat with your claims manager about how you need to set out your reimbursement claim.

We hope that you are able to follow our tips to understand your workers compensation entitlements. If, however, you have a query relating to any of the information in this article, or you require advice about your own matter, please don’t hesitate to get in touch with the Compensation Team of Brazel Moore Lawyers on (02) 4324 7699.