What are “reasonably necessary” medical expenses?

If a worker becomes injured at work, the workers compensation insurer is liable to pay for their medical treatment expenses related to that injury.

Under Section 60(1) of the Workers Compensation Act 1987, an insurer is required to pay for the following types of medical treatment if it is determined to be “reasonably necessary”:

1. any medical or related treatment (other than domestic assistance) to be given, or
2. any hospital treatment to be given, or
3. any ambulance service to be provided, or
4. any workplace rehabilitation service to be provided

The term “reasonably necessary” is assessed on the primary basis of whether there are reasonable prospects that the injured worker’s condition will be improved by the treatment. Additionally, the appropriateness, cost, actual or potential effectiveness and availability of alternate treatments, are also taken into consideration when determining whether a medical expense is reasonably necessary.

There is no finite list of what is considered as reasonably necessary medical or related treatment. Instead, the workers compensation insurer will review the claimed treatment on a case by case basis. This may include treatment assisted by a massage chair, for example, to help with chronic back pain, or a dietician, meal plan or bariatric surgery to assist with weight gained as a result of an injury. Therefore, claims for medical treatment expenses are not limited to appointments with treatment providers. The process of making a claim for medical or related treatment is to provide a recommendation from an appropriately qualified treatment provider to the workers compensation insurer.

Further, section 60(2) of the Act states that “if it is necessary for a worker to travel in order to receive any such treatment or service (except any treatment or service excluded from this subsection by the regulations), the related travel expenses the employer is liable to pay are:

1. the cost to the worker of any fares, travelling expenses and maintenance necessarily and reasonably incurred by the worker in obtaining the treatment or being provided with the service, and
2. if the worker is not reasonably able to travel unescorted—the amount of the fares, travelling expenses and maintenance necessarily and reasonably incurred by an escort provided to enable the worker to be given the treatment or provided with the service.

Therefore, the workers compensation insurer will need to pay for the cost to travel to the medical appointment. This can include the kilometres taken if the injured worker is able to drive themselves or the costs of public transport or a taxi service. These travel expenses need to be confirmed with the workers compensation insurer so the injured worker will need to keep all records ad receipts.

If the injured worker is unable to travel to the appointment on their own, they are also able to claim the travel expenses and maintenance necessary from their escort or support person.

If the insurer declines liability for the claimed treatment expenses, we recommend you contact Turner Freeman as we can assist to ensure you are fairly compensated under such circumstances.