The ability to claim medical, hospital and rehabilitation expenses has long been part of the workers compensation legislation in NSW.
Section 60 of the Workers Compensation Act 1987 provides that injured workers who have made a workers compensation claim are entitled to claim for the reasonable and necessary treatment arising from work injuries.
What does 'reasonably necessary' mean?
Reasonably necessary is dependent on your individual circumstances and the nature of the injury. It does not mean absolutely necessary and also does not mean that if alternate treatment is available it is not reasonably necessary to have the treatment you have proposed. Insurers will consider the appropriateness of the treatment, the effectiveness of the treatment, the cost of the treatment and the medical opinion relating to the treatment.
Pre-approval for treatment
It is always best to get pre-approval for treatment to avoid the insurer refusing to pay for treatment or arguing about the cost or that is was not reasonably necessary, after you have incurred the expense.
There are some instances where pre-approval is not necessary. These include but are not limited to initial treatment within 48 hours of injury, consultations with your nominated treating doctor and treatment in the emergency.
How to claim?
To claim medical expenses, you need to provide the insurer with enough information to consider the treatment. This will normally be in report or capacity certificate from your nominated treating doctor or a specialist.
When can you claim?
The length of time during which medical expenses can be claimed, varies, depending on the assessed level of whole person impairment. For example, workers with a whole person impairment of between 0 and 10% can claim medical and treatment expenses for two years from when weekly payments stop, or from the date of claim if no weekly payments have been made.
The insurer will only pay what is reasonably necessary and is required as a result of the injury. The payment is also made at workers compensation fee levels. If you arrange and pay for treatment the insurer can argue it was not reasonable or necessary, and also not reimburse the full amount of the expense.
Following receipt of all relevant necessary information the insurer has 21 days within which to accept liability or decline liability for a claim for medical expenses.
If you have been injured at work and need advice about your rights and entitlements, please call one of our experienced compensation team in Bathurst, Lithgow or Oberon on 1800 650 656. We're here to help!
Angus Edwards | Principal