TGB partner Tim White discusses what injured Commonwealth workers need to do if their claim is accepted but their medical costs are denied.
Despite my commonwealth work injury being accepted how can a medical treatment cost now be refused?
Increasingly I am seeing injured Commonwealth employees prejudiced with reasonable medical expenses being refused by the relevant insurer or employer in relation to their accepted work injury. Frequently more significant expenses such as surgical costs, prosthesis, pain implants and various other major medical costs are being denied, despite an injured worker having an accepted claim. How can this occur?
When my claim is accepted what does that actually mean longer term?
Under the Safety, Rehabilitation and Compensation Act (SRCA) if liability is accepted for your work injury, that is done so under Section 14 of the SRCA. The effect of such a decision is that they acknowledge that you have sustained a work injury. That is all such a decision does.
However that decision in itself does not determine what entitlements to compensation you have under the SRCA. For example it does not mean you are entitled to medical expenses or weekly payments indefinitely.
What determines how much medical treatment will be covered?
Your entitlements to medical expenses are dealt with via Section 16 of the SRCA.
The threshold test contained in that section says that if the treatment cost is in relation to you work injury and it is reasonable, the insurer is liable to pay that cost. What your GP or treating specialist says about the need for you to have a particular type of treatment is vital to determining if it is reasonable or not. So medical evidence plays a very important role in this process of determining what is reasonable treatment.
What is reasonable varies from case to case and is determined very much on the facts of your individual circumstances. There is a lot of factors to consider when determining whether or not the particular cost you have incurred is reasonable.
Can I dispute a decision refusing to pay for a particular medical cost?
Yes, you most certainly can. If you have received a decision denying payment for particular medical treatment you can dispute that decision. There are some important time limits that apply to disputing such a decision that you need to be aware of, so you should not ignore this sort of decision.
Why are these decisions important to dispute?
It is not only the medical cost that is being denied. It is also any time that you need off work as a result of the medical treatment, that you will also not be covered for under the SRCA.
For example, if surgery has been recommended on your back, and as a consequence of that surgery you will need several months off from work, if the insurer or your employer has denied to cover the cost of your surgery, it follows that the time you lose from work as well will not be paid under the work injury scheme. This could amount to a significant loss of wages, if you are not paid over the period you are not able to work.
In addition to time you are not able to work at all, you may after the surgery have to return back to work on reduced hours initially. Again you will not receive weekly payments under the work injury scheme, whilst you are increasing your hours and returning back to normal duties at work if the cost of the surgery is denied.
So it is not just the medical cost being denied that is important to consider. It is also the ramifications of the lost time from work, and the corresponding lost income.
Should I seek advice?
Generally it is advisable to seek legal advice if you have received a decision refusing to pay for certain medical treatment that has been recommended. Your individual circumstances are very important in determining whether or not your dispute is likely to be successful. Obtaining supportive medical evidence is a very important part of disputing these decisions and asking the doctor the right questions is vital if you are likely to be successful.