We often get emails from injured workers who have been told that their Case Manager won’t pay any more of their medical expenses. These injured workers often go without medical treatment that they need because of this “advice”.
And you know what… it’s wrong. If you have an accepted workers compensation claim then the Case Manager is legally obliged to pay all reasonable medical expenses that you incur as a result of your work related injury.
Workcover medical like expenses
A worker injured in compensable circumstances, whether or not the injury results in time off work, is entitled to payment or reimbursement of reasonable medical and other related expenses. The types of such expenses covered by the Act are set out in section 99 and cover such items as medical, hospital, ambulance, chemist, nursing and travelling expenses, artificial medical aids, as well as treatment by registered chiropractors and osteopaths. Other claims can include personal household and occupational rehabilitation expenses such as home help, gardening, and car and home modifications.
What medical treatment is paid under WorkCover?
- You are entitled to receive medical treatment from the medical practitioner of your choice. You are not obliged to obtain treatment from your employer’s doctor. Your employer’s doctor can of course often provide good treatment particularly in emergencies, but some workers choose to obtain treatment from their own doctors. For major procedures, prior approval from WorkCover is necessary, unless the treatment is urgent.
- All routine medical treatment for your injury is paid by WorkCover. This includes the costs of hospitals, specialists, scans, physiotherapists, chiropractors, chemists etc. If surgery is also required because of your injury, its cost is covered.
- In some circumstances WorkCover will also cover the costs of home help, including gardening.
- WorkCover also covers the cost of gymor swimming if approved by your doctor and if it is necessary to improve or maintain your condition (see entitlements)
Medical treatment costs remain payable after you return to work, or after your weekly payments cease if the treatment is necessary to ensure that your health or your ability to undertake activities of daily living does not deteriorate.
According to the online Law Handbook,the Act states that the expenses must be “reasonable”; that is, they must be reasonable as to the amount of expense, and to the necessity and frequency of treatment.
The liability for payment continues while the injured worker suffers from the effects of the injury, whether there is a return to work or not.
If your Case Manager says they won’t pay for treatment you can challenge that decision and may be able to force the Case Manager to pay the account, or reimburse you for the cost if you have already paid the doctor or physiotherapist etc.
If your doctor wants pre-approval for the costs of surgery or other major treatment (because they won’t proceed without this treatment until they have approval), you can ask your Case Manager to provide their approval. If your Case Manager does not implement a Rehabilitation Program there are also procedural steps that can be taken to force them to do so and a reputable personal injury lawyer can help you with that.
WorkCover has terminated my medical treatment, what should I do?
It is common for WorkCover to terminate or reject medical treatment claims. In fact, WorkCover very closely monitors all medical treatment expenses. The most common expenses that are rejected or terminated relate to long-term physiotherapy or psychological counselling expenses where WorkCover considers that they are not resulting in any therapeutic improvement in your condition.
The most common reasons for a rejection or termination of medical expenses are as follows:
- WorkCover medical advisers have indicated to WorkCover that the treatment is unnecessary.
- WorkCover considers the treatment is no longer is effective or can be replaced by self managed home exercises.
- Weekly payments have ceased more than 52 weeks ago
If WorkCover advise you that they intend to terminate your medical treatment expenses, you should refer the dispute to the Accident Compensation Conciliation Service for resolution of the dispute. One of the most common methods of resolving this type of dispute is to refer the issue to the Medical Panel. When a matter is referred to the Medical Panel, it is often important to be in a position to demonstrate that in the absence of treatment, your condition will worsen. It can sometimes be useful to have a discussion with your treating doctor about whether you should have a brief break in your treatment, particularly physiotherapy treatment to determine the effect of its termination on you.
If your treatment expenses are not restored through conciliation or through a decision of the Medical Panel, it does not mean that your entitlements are finalised for good. If you can demonstrate at a later time that your condition has become worse, making the treatment essential, it is possible to reapply for medical expenses.
We also happen to know of a brilliant WorkCover Assist person, who came highly recommended by our Shine Lawyers. This guy, folks, KICKS BUTT and we would be happy to pass on his details should anyone of you need a butt kicker at Conciliation in Victoria.
If your medical expenses are not being paid by your Case Manager it’s best to contact WorkSafe (workcover), your lawyer, your union and/or workcover assist (for conciliation help).
- Is your requested medical care reasonable and necessary?
- Workcover termination of payments: when insurer suddenly terminates medical expenses