Workcover legislation varies quite a bit from state to state, but one thing all states have in common is the requirement that injured workers be provided all reasonable and necessary medical care. The goal of all work cover jurisdictions is indeed to return the injured worker to work, as quick as possible and to full productivity, if possible or to the level of “maximum medical improvement”. While all injured workers require reasonable and necessary medical care under the law, the difference of opinion in the law starts again when it comes to determining what is reasonable and necessary. It’s always so vague, isn’t it? Same story with the number of independent medical examinations the insurer can send you to: ‘from time to time”; “at reasonable intervals” – why can’t the act be not more specific?
The workcover insurer is obliged to pay for all reasonable medical care for a work-related accident.
Medical care includes not only doctor visits; it also includes (but is not limited to) surgery, hospital stay and care, nursing services, medication, medical equipment, appliance and aids, even gardening services and gym passes. It is however limited to what is reasonable and necessary.
Interestingly, more often than not, workcover case managers – who have little or no medical training whatsoever and who have never ever seen you- will debate or dispute what medical care is reasonable and necessary.
From my own experience and those shared from fellow workcover victims, I have noticed that there appear to be four (4) main areas where the question of “reasonable and necessary” is constantly debated:
1. Special devices/aids/home help
A question that often comes up when a workcover victim has suffered a severe injury is the need for “specialised equipment”.
Whilst the case manager is usually not going to make too much of an issue about the need for crutches or a cane by someone who recently had back surgery, the criteria certainly gets “murky” when the treating doctor states the injured worker needs a motorised wheelchair….
There are, on the market, wheelchairs from $100 to $2000, so which one is reasonable for the insurer to pay for? Well, I suppose that if the injured person is only going to need the wheelchair for a short period of time, one could hire one (and workcover can pay for it); on the other hand, if the injured person is permanently going to be in a wheelchair I believe that a powered deluxe version, with 4 speeds and capable of doing wheelies is ‘reasonable’ and necessary. But here’s the problem, you see, workcover will dispute this and will do everything possible do get you the cheapest piece of trash (which will break within months) and tell you that anything else is “unreasonable and unnecessary”.
I have personally and recently experienced a whole range of issues regarding “home appliances and aids”. First of all, six (6) months after the formal, medical (and urgent) request for home help, I was not only denied home help (“after a thorough and careful review” so they said) but, miraculously, I was offered a few home help appliances and aids as to be “independent”.
Did I tell you that the occupational therapist wrote in his report that “I would be able to clean the house over a period of 3 weeks”. Obviously (sorry, but I NEED to vent), the report conveniently omitted that I live on my own about 3 to 5 days a week (partner interstate on business), that I am unable to get dressed on my own (and therefore stay 3 to 4 days in the same clothes); that I am unable to wash the dishes (and therefore the dishes are piled up in a stinking heap in the sink); that I am unable to prepare a meal (unless it is a frozen meal that I can stick in the microwave) etc, etc.
Well, I was “allowed” to receive a few appliances (of which to date- after 6 months- I received 4 of the 8), so far these include a most inappropriate, extremely cheap, wobbly clothes drying rack, which is far too high (have you ever tried to hang up clothes on a line or rack with 1 non-dominant arm?), a long handled, 2 dollar shop-type, plastic toilet brush (do I really care about cleaning the loo? And why do I need a long handled loo brush for?); a cheap ($80) “steam mop” and a 2 dollar-shop-type long handled bathroom tile scrubber (do I really give a sh*t about scrubbing the wall tiles of my bathroom?). That’s it. I am still waiting on a “plate guard” (a $2-shop-type plastic half moon that you can put on a plate as not to spill food when trying to eat with 1 hand); a plastic “knife and fork in one” (so I can eat on my own and defacto does not need to cut my meat etc like for a child, which I find very embarrassing); a small hand-held hoover (like a bread crumb hoover) and an, what I believe-may-be-useful food preparation system made for disabled people (it’s like a wooden board with pins on it where you can stick on a piece of bread or an apple/carrot etc and actually slice it with 1 hand).
Don’t get me wrong – I am grateful for these ‘toys’ but hey, use some common sense here. I am disabled for life. I need
useful toys and gadgets which will last me a life time. For example an electric can opener would work wonders (so I could open cat food and beans cans); a dishwasher would be heaven so that I could actually wash the dishes and not live surrounded by dirty, stinking dishes; maybe a food chopper so that I could prepare (slice and chop) fruits and veggies for my 2 parrots (and me); and there are quite a few of really useful things for people with 1 arm at the independent living centre .
So, have you ever tried to ‘steam mop’ a floor with a non-dominant arm? I tell you, it’s virtually impossible. The ‘steam mop’ is very difficult to maneuver single handed, and you still have to somehow manage to attach the ‘mop’ to the apparatus and fill the detachable canister with water. You can’t really put pressure with 1 arm and obviously I have trouble actually cleaning the floor (add to that 2 lovely but pooping parrots). Have you tried to use a small hand-vacuum cleaner to hoover your entire house (carpets)? OMG – it sucks – NOT! And who’s making my bed? Who’s changing the linen? Who’s hanging up the washing? Who’s ironing? Who’s maintaining the garden? Who’s cooking? Who’s shopping? Have you tried pushing a supermarket trolley 1-handed? Carried a basket 1 handed AND grab items from a shelf? Who’s driving?
2. Home improvements
3. Massage, hydro therapy
4. Diagnostic testing
Whilst all workcover glossy ‘brochures’ colourfully state that the insurer will basically approve anything the medical provider determines is medically necessary, workcover insurers and case managers will most often dispute the medical necessity of an item or service at any cost, and to the injured victim’s detriment!
We should never ever forget that the Workers Compensation insurance companies are in business, after all, to make a profit. One way to maximise their profits is to pay as little as they can get away with paying on each and every claim submitted. That is the workers compensation insurance case manager’s job.
If you believe that WorkCover has declined to pay for your reasonably required treatment or care , you should appeal the matter at Conciliation (ACCS).