*The contents in this blog relates to legislation in Western Australia.
If a worker’s claim has been accepted for a work related injury, it is important to understand that the workers’ compensation insurer has a discretion to only pay for medical treatment which in their view is “reasonable and necessary”.
If the worker’s treating provider has recommended a specific treatment plan/surgery they must write to the insurer, on behalf of the worker, and seek approval from the insurer to cover the cost of said treatment. A request for approval of treatment will either be accepted, declined or pended subject to the insurer obtaining an independent medical opinion from a specialist of their choosing who will confirm if the treatment is reasonable and necessary. If the insurer does agree to pay for reasonable and necessary medical expenses this does not mean that the worker will lose their right to choose who will treat them nor will they be forced to use a doctor /provider of their employer’s choosing.
If the independent medical specialist engaged by the employer does not agree with the worker’s treating specialist then the treatment will not be approved and the worker will be required to challenge the insurer’s position at a WorkCover hearing.
If this occurs it is strongly recommended that the worker obtain a medico legal report from an Approved Medical Specialist (“AMS”) to further support their treating practitioner’s opinion before commencing the litigation process at WorkCover WA. Further, it needs to be understood that even where there is a supportive medico legal report the insurer will not necessarily change their mind, however a supportive medico legal report will assist the worker to either settle their claim at a Conciliation Conference at WorkCover WA or chose to pursue the matter to Arbitration (where an independent party decides the matter).
It has been our experience that a worker who is legally represented will secure a much better outcome than one attempting to resolve the dispute without legal assistance. As we act on a “No Win, No Fee” basis the worker is provided with reassurance that their legal fees will be deferred until the case has been successfully resolved.* We also cover the cost of our client’s medico legal reports which are usually between $2,000 to $5,000. If your claim is successfully resolved we are able to seek a contribution towards your professional fees from the insurer on top of a settlement and payment of your disbursements.
*additional terms and conditions apply all of which are disclosed in our conditional cost agreement provided when we are retained.
