Medical expenses in NSW workers compensation claims

What Medical and Related Expenses Does the Insurer Pay?

The insurer will pay all reasonable and necessary:

Medical or related treatment

• Treatment by medical practitioners, physiotherapists, chiropractors, osteopaths, psychologists, counsellors, exercise physiologists, remedial massage therapists, other allied health practitioners
• Provision of artificial aids
• Domestic assistance services (only if WPI exceeds 15%)
• Nursing, medical and medicine supplies (provided outside of hospital treatment

Hospital Treatment

• Hospital treatment includes treatment at public and private hospitals and/or rehabilitation centre.

Ambulance Services

• Ambulance services include emergency, non-emergency and inter hospital transfers provided by the Ambulance Service of NSW.

Workplace Rehabilitation Services

• Return to work and case management
• Vocational, functional and workplace assessments
• Job analysis and modification
• Identification of suitable employment
• Worker retraining and placement in suitable employment

Travel Expenses

Any travel expenses incurred related to the workplace attending treatment for the injury, this includes:

• Any fares such as train, bus, or ferry
• Cost of petrol based on the kilometres driven to get to the appointments
• If the injured worker cannot travel alone and needs assistance the insurer must pay for travel assistance.

Do Medical Expenses Require Prior Approval?

Yes,all treatment and services must be approved by the insurer prior to the cost being incurred, otherwise the insurer will not pay.

Note: This does not include any immediate and necessary treatment within 48 hours of the injury.

How do the Expenses get Paid?

You should give to your Doctors your claim number and the Doctor will bill the insurer directly. If you have paid for the treatment yourself, you will need to send to the insurer your invoices including travel expenses as you go.

Can the Insurer Decline Payment?

The insurer can decline payment of any treatment expenses if it does not accept it is reasonable and necessary or that it is not related to your work injury. If the insurer does decline payment they need to put the reasons in writing. This is called a S.74 Notice. This notice sets out why they have declined the treatment expenses and the evidence the insurer relies upon. If you receive a S.74 Notice you should speak to a lawyer immediately.

If the insurer just tells you over the phone that they are not paying for some treatment, this is in breach of the regulation. You should request that the reasons are given to you in writing in a S.74 notice. If the insurer does not do this you should contact WorkCover on 131 050.

How long does the Insurer pay for Treatment?

Payment for medical expenses are paid until;

1. If the WPI* is 10% or less, 2 years after you last received weekly payments.
2. If the WPI is between 11% and 20%, 5 years after you last received weekly payments.
3. If the WPI is 21% and above medical expenses are payable for life.

If you never received weekly payments the period commences from the date of claim.

Note: There are limited exceptions. The insurer does pay for secondary surgery after 2 years if it’s related to the original surgery performed.

*WPI is whole person assessment, assessed by an independent doctor.

Should you have any questions about payment of medical expenses please contact us.