GN 6.7 Aids and modifications

Published: 12 August 2019

Last edited: 11 June 2024

- GN 6.7 Aids and modifications

Application: This guidance applies to exempt workers

Overview

A worker may have an injury that requires an aid or modification to help them in their recovery or activities of daily living.

This guidance assists insurers in understanding what aids and modifications may be compensable under a workers compensation claim, as well as the process for approval, invoicing and payment.

What are aids and modifications?

Aids may include:

crutches, artificial members, eyes or teeth, and other artificial aids or spectacles
any nursing medical or surgical supplies, or curative apparatus, provided for the worker other than as hospital treatment.

Modifications include those made to a worker’s home or vehicle (as directed by a medical practitioner) due to the nature of the worker’s incapacity - see section 59 of the Workers Compensation Act 1987 (1987 Act).

A worker may need equipment to help with personal care (for example, a shower stool or long handled scrubber), housekeeping (like a jar-opening aid), or performing work duties (for example, an ergonomic chair or orthotics in their shoes). Modifications may also be required for a worker’s car or house (for example, a ramp for a wheelchair or a railing in the bathroom).

Insurers can pay the costs for reasonably necessary modifications, where the modifications are required as a result of the work injury. They can also pay the reasonably necessary costs of aids including purchase, hire, delivery, installation and maintenance.

The worker suffered a compensable left knee injury in October 1999. He underwent left knee surgery in December 1999. In 2016, the worker was recommended to undergo total knee replacement surgery by his orthopaedic surgeon. The insurer disputed liability, and the worker commenced proceedings in the Commission.

The Commission determined that the total knee replacement surgery was reasonably necessary medical treatment that was not caught by the time limitations in section 59A(1) and (2) of the 1987 Act.

The employer appealed and in its decision the Court of Appeal confirmed that the knee replacement surgery was reasonably necessary medical treatment as a result of the injury, as it was not caught by the time limitations contained in section 59A(1) and (2) of the 1987 Act and was within the scope of the ‘provision of … other artificial aids’ pursuant to section 59A(6)(a). At paragraph [29], Macfarlan JA said:

'artificial aids' must, as the appellant submits, work to ameliorate the effect of a person’s disability and may comprise a single object or a composite of objects operating together… a knee replacement has these characteristics. According to the parties’ agreement, during the surgery the ends of the femur and the tibia are replaced with an introduced material and a piece of plastic is inserted between the bones as reconstructed. Plainly these materials are designed to facilitate the movement and use of the knee after the operation, therefore easing the patient’s disability. Their 'provision' (see s 59A(6)(a)) cannot occur without a surgical operation. The cost of the operation therefore falls within the statutory provision.

Macfarlan JA considered the cost of the surgery was a cost of the provision of a total knee replacement because it ‘requires surgery’. He commented (at [42]):

I should not be taken to be adopting a general rule that the cost of surgery is always the cost of '[t]he provision of … artificial aids', as there may be many cases where the insertion of material into a person’s body is only an incidental part of major surgery. Each case must be decided on its own facts.

The worker was rendered triplegic in 1972 in an accident giving rise to workers compensation entitlements. With reference to extended definitions of medical and related services in section 59(f) and (g) of the Worker's Compensation Act 1987 he sought rulings on the cost of intended modifications to a house occupied by him since 1987 on a weekly tenancy from the Department of Housing. The modifications were appropriately directed by a medical practitioner. He also sought the expenses of maintaining the yard of the house and obtaining some handyman services.

The case considered what was “reasonably necessary” and the “workers home”. The Compensation Court had held that the home mods were not compensable because of the nature of the tenancy (could be terminated in seven days) and the cost (nearly $240K).

The worker appealed and in it’s judgement, the NSW Court of Appeal held that:

‘The tenure of the premises did not mandate a finding that the proposed modifications could not be "reasonably necessary" in terms of section 60 of the 1987 Act. In that phrase "reasonably" should be construed to moderate any implication of absoluteness in the word "necessary". The Act directs attention to identifying the worker's home, that is, his habitual residence and proper abode and not to tenure except insofar as that may be relevant to identifying and establishing such residence and abode.

Attention to garden and house is not "care (other than nursing care) of a worker in the worker's home" within the ambit of the definition in s59(f). The worker's home is not limited to the residential building and includes the garden and surrounds and such a claim should not be rejected by drawing a distinction between them. The circumstance that care of the garden and handyman services may be of benefit to the worker does not categorize that care as care of the worker himself.’

Approval of aids and modifications

Insurer pre-approval is required for aids and modifications. A request for aids and modifications may come from the nominated treating doctor, the treating specialist, allied health practitioner or rehabilitation provider.

Just as in the case of other entitlements under section 60 of the 1987 Act, when approving aids and modifications, the insurer needs to consider whether:

the aid or modification meets the definitions described in section 59 of the 1987 Act
the treatment or service is for the compensable injury
the treatment or service is reasonably necessary.

The principles of ‘reasonably necessary’ should be applied when approving aids and modifications. Depending on the request, the insurer may need a further assessment or to obtain multiple quotes. See Part 4.2 of the Workers compensation guidelines (the Guidelines) and Insurer guidance GN 6.1 Determining liability for medical and related treatment for more information on determining whether medical or related treatment, as defined by section 59 of the 1987 Act, is reasonably necessary.

Note: The provision of aids and modifications can have a significant impact on a worker’s recovery and requests should be followed-up promptly. A decision must be made within 21 days.

Home modifications

Proof of ownership of the home or the landlord’s written permission should be shown before the insurer can consider home modifications.

Car modifications

The worker must be able to demonstrate a current driver’s licence and proof of ownership of the car before consideration will be made to car modifications. If the vehicle is for the worker to drive, a medical clearance will also be required.

Lifetime entitlement to aids and modifications

Under section 59A(6) of the 1987 Act, workers have no limits on entitlement to the provision of aids and modifications to their home or vehicle to help them with their work-related injury.

Nursing, medicines, medical or surgical supplies or curative apparatus, supplied or provided for the worker other than as hospital treatment are limited by the compensation period. The compensation period under section 59A of the 1987, allows workers to claim medical, hospital, and rehabilitation expenses for:

two years after weekly payments stop or from the date the claim was first made if weekly payments have not been paid or are payable, where their degree of permanent impairment is 10 per cent or less
five years after weekly payments stop or from the date the claim was first made if weekly payments have not been paid or are payable, where their degree of permanent impairment is 11 to 20 per cent.
Workers with greater than 20 per cent permanent impairment are entitled to medical treatment, service or assistance for life.

Medical benefit time limits do not apply to the exempt category of workers (such as police officers, paramedics or fire fighters, coal miners or volunteers).

Invoicing and payment

Invoices should meet SIRA invoicing requirements and should be submitted to the insurer within 30 calendar days of the treatment/service (see Insurer guidance GN 4.3 Invoices and reimbursements).

Working toward best practice

Insurers should call the practitioner if they have questions regarding an invoice. Errors or queries can often be resolved quickly over the phone, and this is beneficial to all parties. If telephone contact is unsuccessful, then an email or letter should be sent seeking clarification.

Insurers should always attempt to resolve an issue rather than just not pay an invoice. Non-payment of an invoice can be detrimental to the insurer-health practitioner relationship, and negatively impact the worker’s recovery.

Insurers are to pay provider invoices promptly. Prompt payment is considered to be within ten calendar days or the provider’s specified business terms, whichever is later. It is preferable that payments to providers are made by Electronic Funds Transfer (EFT).

GN 6.6 Referral to an injury management consultant

GN 6.8 Independent medical examinations

Related: Legislation and regulations

Related: Guidelines and standards