Therapeutic Devices and Pre-Approval under the Return to Work Act
Under the Return to Work Act, strict time frames apply with regards to payments of medical expenses caused by a work related injury which differ from the previous WorkCover regime.
In order to ensure that your expenses are covered it is important to understand these time frames as well as exceptions which may be available to you for payment of your medical expenses after your entitlement period ceases.
What are the time frames for claiming my reasonable medical expenses?
Your entitlement period will depend on when your injury or illness occurred and the extent of your injury.
If you suffer from an “existing injury” (meaning an injury which was sustained prior to 1 July 2015) it is important to note that your entitlements have now changed and you are only entitled to payment of your reasonable medical expenses for a period of 1 year after the Return to Work Act came into force (i.e. until 1 July 2016), or 12 months after your entitlement to weekly payments ceases, whichever is the latter.
If you have suffered an injury after 1 July 2015 you are entitled to payment of your reasonable medical expenses for a period of 1 year after the date of your accident, or 12 months after your entitlement to weekly income maintenance payments ceases, whichever is the latter.
An exception to the above applies however to “seriously injured” workers. To be “seriously injured” under the Return to Work Act, you must have a whole person impairment of 30% or more. As discussed in our previous blog regarding seriously injured workers, if you are assessed as having a “serious injury” you will be entitled to medical expenses related to your work-related injury or illness on a lifetime basis.
For further information about your entitlement periods we invite you to read our earlier blog regarding Medical Expenses under the Return to Work Act.
What happens if I need ongoing support after my entitlement period ceases?
Unfortunately, you will not be able to claim your work-related medical expenses outside of the specified time frames unless you meet one of the specific exceptions outlined in the Return to Work Act as follows:
If you are injured and require surgery after the date your entitlement period ceases you are required to submit a pre-approval application to your relevant claims agent or self-insured employer before the date on which your entitlement ceases.
If you do not apply for pre-approval prior to your entitlement period ending, you will not be able to claim your expenses for surgery and associated treatment (such as rehabilitation) and will be forced to self-fund the costs of your surgery and associated expenses.
If you require a therapeutic device or appliance in relation to a work related injury you may be able to claim your out of pocket expenses beyond your initial entitlement period.
This exception covers expenses such as:
- spectacles or contact lenses;
- a hearing aid;
- false teeth;
- a prosthesis;
- a crutch or wheelchair; and
- any other appliance or aid for reducing the extent of an injury or enabling a person to overcome in whole or part the effects of an injury.
The exception includes a provision that the appliance be required to maintain a “worker’s capacity” and there is still some debate amongst the legal community as the whether this exception will apply to workers who are employed (and require the appliance to sustain their employment) or whether a worker’s need for the appliance will give rise to a lifetime entitlement.
Pre-approval should be sought for all therapeutic devices to ensure that you are not left out of pocket if there is a dispute regarding your need for a therapeutic appliance.
If you require surgery or a therapeutic appliance and require assistance to obtain pre-approval for these expenses please contact our Adelaide office on (08) 8213 1000 and ask to speak to one of our workers compensation lawyers.