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Insurers continue to deny reasonably necessary medical treatment

In late 2012 the worker tripped and injured his left knee and right hand while at work.

His orthopaedic surgeon recommended minimally invasive arthroscopic surgery on his left knee. Unfortunately, the insurer disputed liability.

Significant time had passed with the insurer continuing to dispute liability to pay for the arthroscopic surgery. However, in April of 2014 the insurer finally agreed to pay for arthroscopic surgery. By this time the workers condition had significantly deteriorated and the worker was advised by his orthopaedic surgeon that arthroscopic surgery was no longer an option and that a total knee replacement was now necessary.

During the time that the insurer was disputing liability for the arthroscopic surgery the worker had a number of falls due to his left knee failing. Subsequently the worker sustained further injury to his right wrist, right shoulder, and cervical spine.

The worker commenced proceedings in the Commission for weekly compensation for hospital and medical expenses for the initial injury to his left knee and his subsequent injuries.

The insurer denied liability on the basis that the workers only required a total knee replacement because of arthritis which was due to a motorbike accident some 25 years ago, not a workplace accident.

In late 2015 an Arbitrator for the Commission found in favour of the worker in all regards and the worker was awarded weekly compensation. However, the employer appealed.

On Appeal the Arbitrators’ decision was upheld as in order to establish that treatment should be paid for by the insurer the worker needs to establish that the treatment was ‘reasonably necessary’ which means that it is ‘reasonably necessary’ as a result of the injuries. It does not need to be reasonable and necessary. It merely needs to be appropriate in relation to the injuries sustained.

The Appeal Arbitrator was also satisfied that the presence of osteoarthritis in the left knee did not significantly contribute to the need for a total knee replacement, and that the injuries sustained from the workplace accident in 2012 contributed significantly to the need for surgery.

The Appeal Arbitrator found that the subsequent injuries were sustained as a result of the initial knee injury that arose out of the workplace fall in 2012.

This case is yet another example of the insurer delaying payment for reasonable and necessary medical expenses. Such delay often comes at the expense of the injured worker by way of exacerbating their injuries.

When the insurance company finally agreed to pay for the arthroscopic surgery it was too late. When they found out that they were now required to pay for a total knee replacement which is a significantly more expensive procedure, they disputed liability.

We see this sort of behaviour from insurers all too often. They accept liability when it suits them, but when it doesn’t suit them they will dispute liability on any grounds, such as that the injury was caused by a prior motor vehicle accident some 25 years ago.

Luckily this case resolved in favour of the injured worker, however due to the delay by the insurer the workers’ injuries worsened and they had to wait over 4 years for the claim to be resolved.

Workers’ compensation claims are very difficult and complicated. If you’re having similar problems with your workers’ compensation claim, you should contact an Accredited Specialist in Personal Injury Law to help you.

Garling & Co Lawyers

Matthew Garling

Matthew Garling is an Accredited Specialist in Personal Injury Law approved by New South Wales Law Society. He is admitted to practice in the Supreme Court of NSW and the High Court of Australia. Matthew is also a member of...
Lisa L.
05:18 13 Jul 24
Outstanding service and commitment to my case was delivered from the first point of contact right until the end of my successful case.Highest recommendations to the team at Garling and Co. Matthew... got me an excellent result and was available and informative throughout the entire foreign process of legal proceedings. He was wonderful and so was his team.If i could rate higher than 5 stars i would!read more
J B
07:12 02 Jul 24
Matthew Garling and all of the team were extremely professional and supportive throughout what was a very long and arduous CTP battle. I am happy with the result and feel that their fees were fair... and well deserved.read more
Nelson B.
02:11 30 Jun 24
Professional, prompt & honest service
Brad M.
02:19 28 Jun 24
I worked with Garling & Co for 3+ years, the team has been incredible and I could not have been happier with Kerry's support and the results produced!I highly recommend choosing them as your... representatives!!read more
Ray H.
07:33 13 Jun 24
Matthew Garling and Team are kind, patient, polite, professional, empathetic and efficient. I was treated terribly by the at fault insurer. Garling and Co. had my back. Matthew gently and patiently... kept me up to speed on all the steps to go through. From my personal experience I recommend these guys. They are safe hands. Thank you team.read more
Jo L.
05:58 07 May 24
So very impressed with the professional team who looked after me throughout the last 4 and 1/2 years. A special mention to Kerry and Nathan who navigated each request to fight for my right to gain... access to further treatments and physio and to ensure medical treatment would be covered moving forward. I was so grateful I could hand it all over to you and not have to go through this very challenging time without your support.I thank you for the compassion you have provided to me, from the first contact with Matthew and Natasha, to finalisation with Kerry and Nathan.I highly recommend the team at Garling and Co for any third party compensation claims. You are in good hands with them all.read more
Linda O.
21:53 06 May 24
Emma, Rebecca and the team at Garling and Co have worked diligently throughout my workers compensation claim. The level of professionalism, support and communication has been faultless. Of particular... note has been the sensitivity displayed to me throughout the lengthy process. Worker’s compensation claims are complex and not easy to navigate, particularly when you are unwell. I do not hesitate to recommend Garling and Co to help you find a way through this otherwise unfathomable system.read more
Keith H.
20:51 23 Apr 24
After my case stalled with another firm, I decided to give Matthew Garling a call. He took my case and not only won, but achieved an outcome that far exceeded my expectations. This firm is the best... in the business in my opinion and I wouldn't hesitate to recommend them to anyone.read more
Anthony T.
00:50 16 Apr 24
Thank you Matthew and his team who guided me through the legal process, a truly positive experience with total professionalism.
Mikaele N.
03:01 15 Apr 24
Garling &Co Lawyers were awesome, I called every compensation law firm and was told that I couldn't claim for compensation.The whole experience and process was simple and stress free.Mr Matthew... Garling and Allison deserve an accolades for the very best in client service. I would highly recommend their service to anyone.read more
READ ALL TESTIMONIALS

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Lisa L.
05:18 13 Jul 24
Outstanding service and commitment to my case was delivered from the first point of contact right until the end of my successful case.Highest recommendations to the team at Garling and Co. Matthew... got me an excellent result and was available and informative throughout the entire foreign process of legal proceedings. He was wonderful and so was his team.If i could rate higher than 5 stars i would!read more
J B
07:12 02 Jul 24
Matthew Garling and all of the team were extremely professional and supportive throughout what was a very long and arduous CTP battle. I am happy with the result and feel that their fees were fair... and well deserved.read more
Nelson B.
02:11 30 Jun 24
Professional, prompt & honest service
Brad M.
02:19 28 Jun 24
I worked with Garling & Co for 3+ years, the team has been incredible and I could not have been happier with Kerry's support and the results produced!I highly recommend choosing them as your... representatives!!read more
Ray H.
07:33 13 Jun 24
Matthew Garling and Team are kind, patient, polite, professional, empathetic and efficient. I was treated terribly by the at fault insurer. Garling and Co. had my back. Matthew gently and patiently... kept me up to speed on all the steps to go through. From my personal experience I recommend these guys. They are safe hands. Thank you team.read more
Jo L.
05:58 07 May 24
So very impressed with the professional team who looked after me throughout the last 4 and 1/2 years. A special mention to Kerry and Nathan who navigated each request to fight for my right to gain... access to further treatments and physio and to ensure medical treatment would be covered moving forward. I was so grateful I could hand it all over to you and not have to go through this very challenging time without your support.I thank you for the compassion you have provided to me, from the first contact with Matthew and Natasha, to finalisation with Kerry and Nathan.I highly recommend the team at Garling and Co for any third party compensation claims. You are in good hands with them all.read more
Linda O.
21:53 06 May 24
Emma, Rebecca and the team at Garling and Co have worked diligently throughout my workers compensation claim. The level of professionalism, support and communication has been faultless. Of particular... note has been the sensitivity displayed to me throughout the lengthy process. Worker’s compensation claims are complex and not easy to navigate, particularly when you are unwell. I do not hesitate to recommend Garling and Co to help you find a way through this otherwise unfathomable system.read more
Keith H.
20:51 23 Apr 24
After my case stalled with another firm, I decided to give Matthew Garling a call. He took my case and not only won, but achieved an outcome that far exceeded my expectations. This firm is the best... in the business in my opinion and I wouldn't hesitate to recommend them to anyone.read more
Anthony T.
00:50 16 Apr 24
Thank you Matthew and his team who guided me through the legal process, a truly positive experience with total professionalism.
Mikaele N.
03:01 15 Apr 24
Garling &Co Lawyers were awesome, I called every compensation law firm and was told that I couldn't claim for compensation.The whole experience and process was simple and stress free.Mr Matthew... Garling and Allison deserve an accolades for the very best in client service. I would highly recommend their service to anyone.read more
University of Technology, Sydney
Member of Law Society of New South Wales
Law Society of NSW Specialist Accreditation
University of Sydney
Legal Profession Admission Board of New South Wales
The law society of nsw professional standards scheme logo.
University of Technology, Sydney
Member of Law Society of New South Wales
Law Society of NSW Specialist Accreditation
University of Sydney
Legal Profession Admission Board of New South Wales
The law society of nsw professional standards scheme logo.
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