detailWorkers Compensation

Accessing medical treatment

Accessing medical treatment

Under the legislation unless you are an exempt worker, the insurer will not approve medical services unless preapproval is given. An exempt worker is a police officer, a firefighter or a paramedic.

Workers can claim reasonably necessary medical treatment and expenses. Section 59 of the 1987 act sets out the definitions of hospital and medical treatment as follows:

Division 3 Compensation for medical, hospital and rehabilitation expenses etc

59   Definitions

(cf former s 10 (2))

In this Division—

ambulance service  includes any conveyance of an injured worker to or from a medical practitioner or hospital.

 means treatment (including treatment by way of rehabilitation) at any hospital or at any rehabilitation centre conducted by a hospital and includes—

(a)  the maintenance of the worker as a patient at the hospital or rehabilitation centre,

(b)  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

(c)  any other ancillary service,

but does not include ambulance service.

medical or related treatment  includes—

(a)  treatment by a medical practitioner, a registered dentist, a dental prosthetist, a registered physiotherapist, a chiropractor, an osteopath, a masseur, a remedial medical gymnast or a speech therapist,

(b)  therapeutic treatment given by direction of a medical practitioner,

(c)    (Repealed)

(d)  the provision of crutches, artificial members, eyes or teeth and other artificial aids or spectacles,

(e)  any nursing, medicines, medical or surgical supplies or curative apparatus, supplied or provided for the worker otherwise than as hospital treatment,

(f)  care (other than nursing care) of a worker in the worker’s home directed by a medical practitioner having regard to the nature of the worker’s incapacity,

(f1)  domestic assistance services,

(g)  the modification of a worker’s home or vehicle directed by a medical practitioner having regard to the nature of the worker’s incapacity, and

(h)  treatment or other thing prescribed by the regulations as medical or related treatment,

but does not include ambulance service, hospital treatment or workplace rehabilitation service.

public hospital means—

(a)  a public hospital within the meaning of the Health Services Act 1997 controlled by a local health district or the Crown,

(b)  a statutory health corporation or affiliated health organisation within the meaning of the Health Services Act 1997,

(c)    (Repealed)

(d)  a hospital or other institution (whether in this State or in another State or a Territory of the Commonwealth) that—

(i)  is prescribed by the regulations, or

(ii)  belongs to a class of hospitals or institutions prescribed by the regulations,

for the purposes of this definition.

workplace rehabilitation service means 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.

Section 60 (2A) of the 1987 Act sets out the types of treatment or services that are exempt from the requirement to obtain prior approval from the insurer.

60   Compensation for cost of medical or hospital treatment and rehabilitation etc

(1)  If, as a result of an injury received by a worker, it is reasonably necessary that—

(a)  any medical or related treatment (other than domestic assistance) be given, or

(b)  any hospital treatment be given, or

(c)  any ambulance service be provided, or

(d)  any workplace rehabilitation service be provided,

the worker’s employer is liable to pay, in addition to any other compensation under this Act, the cost of that treatment or service and the related travel expenses specified in subsection (2).

Note—

Compensation for domestic assistance is provided for by section 60AA.

(2)  If it is necessary for a worker to travel in order to receive any such treatment or service (except any treatment or service excluded from this subsection by the regulations), the related travel expenses the employer is liable to pay are—

(a)  the cost to the worker of any fares, travelling expenses and maintenance necessarily and reasonably incurred by the worker in obtaining the treatment or being provided with the service, and

(b)  if the worker is not reasonably able to travel unescorted—the amount of the fares, travelling expenses and maintenance necessarily and reasonably incurred by an escort provided to enable the worker to be given the treatment or provided with the service.

(2A)  The worker’s employer is not liable under this section to pay the cost of any treatment or service (or related travel expenses) if—

(a)  the treatment or service is given or provided without the prior approval of the insurer (not including treatment provided within 48 hours of the injury happening and not including treatment or service that is exempt under the Workers Compensation Guidelines from the requirement for prior insurer approval), or

(b)  the treatment or service is given or provided by a person who is not appropriately qualified to give or provide the treatment or service, or

(c)  the treatment or service is not given or provided in accordance with any conditions imposed by the Workers Compensation Guidelines on the giving or providing of the treatment or service, or

(d)  the treatment is given or provided by a health practitioner whose registration as a health practitioner under any relevant law is limited or subject to any condition imposed as a result of a disciplinary process, or who is suspended or disqualified from practice.

(2B)  The worker’s employer is not liable under this section to pay travel expenses related to any treatment or service if the treatment or service is given or provided at a location that necessitates more travel than is reasonably necessary to obtain the treatment or service.

(2C)  The Workers Compensation Guidelines may make provision for or with respect to the following—

(a)  establishing rules to be applied in determining whether it is reasonably necessary for a treatment or service to be given or provided,

(b)  limiting the kinds of treatment and service (and related travel expenses) that an employer is liable to pay the cost of under this section,

(c)  limiting the amount for which an employer is liable to pay under this section for any particular treatment or service,

(d)  establishing standard treatment plans for the treatment of particular injuries or classes of injury,

(e)  specifying the qualifications or experience that a person requires to be appropriately qualified for the purposes of this section to give or provide a treatment or service to an injured worker (including by providing that a person is not appropriately qualified unless approved or accredited by the Authority).

(3)  Payments under this section are to be made as the costs are incurred, but only if properly verified.

(4)  The fact that a worker is a contributor to a medical, hospital or other benefit fund, and is therefore entitled to any treatment or service either at some special rate or free or entitled to a refund, does not affect the liability of an employer under this section.

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