Lawyers assist in relation to a variety of different matters in relation to workers compensation claims. One which includes what is reasonably necessary medical treatment. The Workers Compensation Act 198 outlines what the insurer is required to attend.

Once your claim is accepted, the workers compensation insurer will attend to the payment of your loss of wages and medical and treatment expenses including medical, hospital or rehabilitation treatment or services based on the details of your injury.

What is reasonably necessary treatment:

This is a legal test set out in section 60 of the Workers Compensation Act 1987 (NSW) sets out rules for determining whether medical or related treatment, is reasonably necessary as defined by section 59 of the 1987 Act.

When considering the facts, the insurer needs to consider the following:

  • what is determined as reasonably necessary for one worker may not be reasonably necessary for another worker with a similar injury;
  • reasonably necessary does not mean absolutely necessary;
  • Evidence based on medical experts.

If the insurer remains unclear whether a treatment required, they then move onto the following elements:

  • The appropriateness of the particular treatment
  • The availability of alternative treatment
  • The cost of the treatment
  • The actual or potential effectiveness of the treatment
  • The acceptance of the treatment by medical experts.

Is approval required before receiving treatment?

It is vital under the Workers Compensation Act (NSW) 1987, section 60 (2A) that prior approval for any service and or treatment be approved before you receive any treatment or service. Should you require any approval, its best to talk to Turner Freeman Lawyers were we are able to assist. Once the treatment is received, by the insurer, the insurer has 21 days to provide a response.

We note, you do not require approval for any treatment necessary within 48 hours of injury. 

When is the insurer not liable to cover costs:

  1. The treatment or service is given or provided without the prior approval of the insurer (not including treatment provided within 48 hours of the injury happening and not including treatment or service that is exempt under the Workers Compensation Guidelines from the requirement for prior insurer approval), or
  2. The treatment or service is given or provided by a person who is not appropriately qualified to give or provide the treatment or service, or
  3. The treatment or service is not given or provided in accordance with any conditions imposed by the Workers Compensation Guidelines on the giving or providing of the treatment or service, or
  4. The treatment is given or provided by a health practitioner whose registration as a health practitioner under any relevant law is limited or subject to any condition imposed as a result of a disciplinary process, or who is suspended or disqualified from practice. 

What to do if you are declined for treatment:

If you receive a section 78 notice where any treatment is declined, you should contact Turner Freeman lawyers to assist. The insurer must provide reasoning as to why the medical treatment is not classified as “Reasonably necessary.”

You should consult with Turner Freeman who will provide you advice in relation to this.

How long can I receive Medical and treatment expenses?

The Act caps the entitlement to medical costs so that the insurer only has to pay those costs for various periods depending on your level of impairment:

  1. If your injury has resulted in a degree of impairment assessed to be 10% whole person impairment or less, or the degree of impairment has not been assessed, the entitlement period has been extended to 2 years commencing on the date on which the claim for compensation in respect of injury was first made or the date on which weekly payment of compensation ceased to be payable to the worker.
  2. If your injury has resulted in a degree of impairment assessed to be at least 11% but not more than 20% whole person impairment the period is extended to 5 years and commences on the date on which the claim for compensation of injury was first made or the last date on which weekly payments of compensation ceased to be made.
  3. No time limitation applies to a worker who is assessed to have suffered from an impairment greater than 20% whole person impairment.
  4. Finally, the time limitation on medical related expenses does not apply to any compensation sought in respect of any of the following medical or related treatment:
    1. the provision of crutches, artificial members, eyes or teeth and other artificial aids or spectacles (including hearing aids and hearing aid batteries);
    2. the modification of a home or vehicle;
    3. Secondary surgery (secondary surgery must be directly consequential on the earlier surgery and must be approved by the insurer within two years after the earlier surgery was approved).

At Turner Freeman Lawyers, we assist and help you to your entitlements to payment of or reimbursement for the medical, hospital, pharmaceutical and other expenses you have incurred as a result of your injuries as long as those expenses are reasonable.

This may also include payment for rehabilitation and in some circumstances home care. It also will include payment for travelling expenses in attending medical or other treatment. It best you contact our offices and speak to a trusted and experienced lawyer.