Medical and related services

Overview

Workers are entitled to be compensated for the cost of reasonably necessary medical or hospital treatment and rehabilitation expenses incurred as a result of a work-related injury.

Insurers are required to make liability decisions for medical or related treatment in a timely, fair and transparent manner.

This guidance addresses what to consider when determining a treatment request and communicating the decision to the worker.

Determining a treatment request

An insurer is required to determine a claim for medical expenses compensation within 21 days - section 279 of the Workplace Injury Management and Workers Compensation Act 1998 (1998 Act).

Medical, hospital and rehabilitation expenses are to be paid where the treatment or service:

• meets the definitions of the various treatments or services described in section 59 of the Workers Compensation Act 1987 (1987 Act)
• takes place while the worker is entitled to receive compensation (the compensation entitlement period) for medical, hospital and rehabilitation expenses
• is reasonably necessary because of the injury (see below for discussion on reasonably necessary)
• is pre-approved by the insurer (unless the treatment or service is exempt from pre-approval – see Insurer guidance GN 3.4 Pre-approval of treatment)
• is provided by a person who is appropriately qualified as per Part 4 of the Workers compensation guidelines (the Guidelines).

Definition of treatment

Treatment is defined in section 59 of the 1987 Act as:

• ambulance service including any conveyance of a worker to/from a medical practitioner or hospital
• hospital treatment (including treatment by way of rehabilitation) at any hospital or rehabilitation centre conducted by a hospital (excluding ambulance service) including:
  • the maintenance of the worker as a patient at the hospital or rehabilitation centre
  • the provision or supply by the hospital, at the hospital or rehabilitation centre, of nursing attendance, medicines, medical or surgical supplies, or other curative apparatus, and
  • any other ancillary service
• medical and related treatment including:
  • treatment by a medical practitioner, registered dentist, dental prosthetist, registered physiotherapist, chiropractor, osteopath, massage therapist, remedial medical gymnast (exercise physiologist) or a speech therapist
  • therapeutic treatment given by direction of a medical practitioner
  • the provision of crutches, artificial members, eyes or teeth and other artificial aids or spectacles
  • any nursing, medicines, medical or surgical supplies or curative apparatus, supplied or provided for the worker otherwise than as hospital treatment
  • care (other than nursing care) of a worker in their home as directed by a medical practitioner in relation to the worker’s incapacity
  • domestic assistance services
  • the modification of a worker’s home or vehicle as directed by a medical practitioner having regard to the nature of the worker’s incapacity, and
  • treatment or other thing prescribed by the regulations as medical or related treatment
• workplace rehabilitation service meaning any service provided as a workplace rehabilitation service by or on behalf of a provider of rehabilitation services approved under section 52 of the 1998 Act.

For further information about entitlements to aids and modifications refer to Insurer guidance GN 6.7 Aids and modifications.

Entitlement period for treatment and services

Workers may claim medical, hospital and rehabilitation expenses during a specific compensation entitlement period.

Section 59A of the 1987 Act sets out the limits to payment of compensation and the relevant compensation period for a worker.

The compensation period starts:

• the day on which the claim was first made (if weekly payments have not been paid or payable), or
• the day on which weekly payments cease to be payable to the worker.

The end of the compensation period depends on the worker’s assessed level of permanent impairment. See the table below for further details.

Reasonably necessary

If, as a result of an injury received by a worker, it is reasonably necessary that medical, hospital, ambulance or workplace rehabilitation be provided, the worker's employer is liable to pay (see section 60 of the 1987 Act). Before approving or paying for the treatment or service, an insurer should determine, based on the facts of each case, whether the treatment or service is:

• required as a result of the injury, and
• reasonably necessary.

When considering the facts of the case, the insurer should be aware that:

• what is determined to be reasonably necessary for one worker may not be reasonably necessary for another worker with a similar injury
• reasonably necessary does not mean ‘absolutely necessary’
• although evidence may show that a similar outcome could be achieved by an alternative treatment, it does not mean that the treatment recommended is not reasonably necessary.

The matter of Taxis Combined Services (Victoria) Pty Ltd v Schokman [2014] NSWWCCPD 18 dealt with an appeal concerning liability for the cost of proposed dental treatment as a result of an accepted facial injury more than twenty years prior.

In the matter of Diab v NRMA Ltd the Deputy President considered whether knee surgery was ‘reasonably necessary’ as a result of accepted work injuries.

Appropriately qualified

In the NSW workers compensation scheme, allied health services are provided by appropriately qualified and SIRA-approved allied health practitioners.

SIRA-approved allied health practitioners are approved in accordance with the SIRA Guidelines for approval of treating allied health practitioners. They supply their approval number, along with treatment requests, on the Allied Health Treatment Request (AHTR).

Each month, SIRA sends insurers an updated list of approved allied health practitioners (with their approval numbers) so insurers can ensure they are only approving and paying for services provided by appropriately qualified SIRA-approved practitioners.

Determining liability for medical expenses

NSW workers compensation legislation requires liability for medical expenses to be determined within 21 days of a claim being submitted.

The insurer should consider all available information when determining liability for medical or related treatment. This may include:

• the treatment request
• certificates of capacity
• medical reports from nominated treating doctors and specialists
• discussions with stakeholders, including the worker
• independent consultant reports
• clinical records
• reports from an independent medical examination (IME).

The insurer should review the proposed treatment request against the principles of the Clinical framework for delivery of health services (Clinical framework). All Health practitioners are expected to adopt the principles of the Clinical framework when delivering services in the workers compensation scheme.

Most treatment can be approved by reviewing the treatment request and the information already available on the claim file. A phone call with the nominated treating doctor or allied health practitioner is usually the quickest and most direct way to obtain any missing information.

When additional information is required

On some occasions, an insurer may need to collect further information to help determine liability. If necessary, the insurer should request specific tailored information from the:

• nominated treating doctor
• medical specialist/ surgeon proposing the procedure/treatment
• independent consultant, or
• independent medical examiner.

A referral to an independent medical examiner is only appropriate where information from treating practitioners is inadequate, unavailable or inconsistent and the insurer in unable to resolve these issues directly with the treating practitioners.

Specific tailored information requested by an insurer to assist determining liability may include:

• details of the specific procedure/treatment
• clarification on the need for the specific procedure/treatment
• the procedure/treatment’s relationship to the injury
• proposed date when the procedure/treatment will be provided
• cost of procedure/treatment
• expected timeframe for recovery and return to work
• the type, frequency and duration of any post procedure/treatment rehabilitation.

An insurer may wish to obtain an update on progress to determine whether a particular ongoing medical or treatment expense is reasonably necessary. Insurers should consider requesting an update regarding a medical or treatment expense where:

• the worker’s capacity is not improving
• the treatment is inconsistent with the worker’s injury
• there may be a more effective, alternative course of treatment
• the worker is seeking an excessive level of medical or treatment services
• the level of servicing is increasing over time.

Progress can be assessed by contacting a practitioner by telephone, requesting a brief written progress update or, for allied health practitioners through review of an AHTR.

Communicating liability decisions to the worker

Insurers should acknowledge requests for treatment/services as they are received. An insurer should keep workers informed about any updates, including when they should expect a decision on a treatment/service request.

Treatment decisions are to be notified in writing. Approvals for surgery should be notified in writing and should clearly specify what is being approved.

The insurer is to outline any reasons for declining services or approving some services only.

It is best practice for insurers to obtain and review surgical item numbers and costs in relation to relevant gazetted Fees Order/s before approving surgery to ensure compliance with rules and maximum fees. However, care should be taken not to unnecessarily delay surgery approval while waiting for clarification on surgical item numbers.

The insurer should advise relevant parties of the outcome and reasons for a decision regarding liability for medical and related treatment (see expectations outlined in Standard of practice S4. Liability for medical or related treatment).

Disputing treatment

Any decision to dispute liability for treatment should be made in the context of the claim in its entirety. It should also follow principles of procedural fairness and appropriate and sound decision-making process (see Insurer guidance GN 1.5 Procedural fairness for more information). When treatment is not approved, a decision notice must be issued to the worker. See Insurer guidance GN 8.1 Insurer decision and decision notice requirements.

If the insurer disputes liability (for the claim or treatment) after previously approving treatment, it should advise any provider(s), in a timely manner, that the services are no longer approved.