Medical Expenses & Reasonably Necessary Test in WC Claim

In Section 60 of the Worker Compensation Act 1986 (NSW) (the 1987 Act) an injured worker can claim work-related medical or hospital treatment and rehabilitation if they are reasonably necessary.  The 1987 Act does not define reasonably necessary treatment. However in the case of Diab v NRMA Ltd [2014] NSWWCCPD 72 (Diab), Roche DP has clarified what reasonably necessary treatment means.

In determining reasonableness, Roach DP held that the factors to be taken into account may include but not necessarily limited to:

1. the appropriateness of the particular treatment;
2. the availability of alternative treatment, and its potential effectiveness;
3. the cost of the treatment;
4. the actual or potential effectiveness of the treatment, and
5. the acceptance by medical experts of the treatment as being appropriate and likely to be effective. 

In another case, Shipp v Community First Development Ltd t/as Indigenous Community Volunteers [2021] NSWPIC 2 (4 March 2021), the Applicant sustained a lumbar injury during the course of her employment.

Despite several episodes of injection treatments the applicant still reported severe lower back pain. The Applicant’s treating doctor then suggested the Applicant undertake bariatric surgery for weight loss to effectively ameliorate her lower back pain. 

Member Elizabeth Beilby held that all of the doctors’ placed significant importance upon weight loss to primarily reduce pain and there is evidence provided by applicant showing that alternative pain management has no significant benefit. Member Beiby also noted that the Applicant was not required to pursue all alternative weight loss paths as the insurer for the employer did not file any evidence to consider the efficacy of alternative treatments.

Conclusion

In order to claim medical benefits the worker must first show that the work-related injury materially contributed to the need for the treatment. Secondly, that the proposed treatment is reasonably necessary. 

If your proposed medical treatment is refused by the insurer, please contact our experienced personal injury team of Longton Legal at 02 8355 9999.

>Michelle Riordan, Resolution of disputes under Section 60 of the Workers Compensation Act 1987 (NSW) in the Personal Injury Commission. December 2021. See here.