Medical Expenses

The insurer is required to pay “reasonably necessary” medical expenses. In determining what treatment is reasonably necessary, the insurer should have regard to:

• The appropriateness of the treatment.
• The availability of alternative treatment.
• The cost of the treatment.
• The actual potential effectiveness of the treatment.
• The acceptance by medical experts of the treatment as being appropriate and likely to be effect.

The term has also been defined to mean “any necessity for relevant treatment which results from the injury where its purpose and potential effect is to alleviate the consequence of injury”.

Often this test is confused to mean that the treatment must be reasonable and necessary. This is incorrect. That is a much more demanding test.

If the treatment is such that its potential effect is to alleviate the consequence of injury, then it will be “reasonably necessary”

Section 60 (2A) of the Workers Compensation Act states that the insurer is not liable to pay for the cost of medical treatment without prior approval of the insurer.

However, there are several exceptions where no prior approval is required and they include the following:

• Any treatment provided within 48 hours of the injury.
• Attending a nominating treating doctor for a consultation or to obtain a medical certificate.
• The first consultation with a specialist medical practitioner on referral by the nominated treating doctor.
• All plain x-rays performed on referral from a nominated treating doctor or specialist medical practitioner.
• Any service provided in a public hospital on presentation to an emergency department.
• In relation to physiotherapy, osteopathic or chiropractic treatment, the initial consultation and up to a further 7 treatment sessions provided the practitioner is registered and the injured worker has not previously received such treatment for the injury claimed.
• Pharmacy items prescribed by the nominating treating doctor within the first 3 weeks’ post injury up to a maximum of $500.00.
• For any psychological treatment or counselling, the initial consultation and up to a further 5 treatment or counselling sessions where the counsellor is WorkCover approved and the worker has not previously received such counselling.
• Payment of up to 5 sessions of remedial massage however the remedial massage therapist must be WorkCover approved.
• In relation to a hearing needs assessment, the initial hearing needs assessment as long as such assessment was referred by the nominated treating doctor or treating specialist.
• The Workers Compensation Commission or a registrar orders the insurer to pay for treatment expenses.

When you request pre-approval from the insurer, the insurer has a period of 21 days to respond to your request. If the insurer does not respond within 21 days, you can make a complaint to the WorkCover independent Review Office (WIRO).

If the treatment has been pre-approved and receipts have been sent to the insurer for reimbursement, the insurer must reimburse you within seven days of receiving your expenses receipts.

The period the insurer is responsible for paying reasonably necessary medical treatment differs depending on your assessment of whole person impairment (WPI):

• 10% WPI or less: payment of medical expenses will cease 2 years from the date of the claim was made or from the date that weekly payments cease (whichever occurs later).
• 11% to 20% WPI: payment of medical expenses will cease 5 years from the date that the claim was made or from the date that weekly payments cease (whichever occurs later).
• 21% or more WPI: payment of medical expenses are payable for the remainder of the injured workers life.

The insurer may decline to pay for your medical expenses on the basis that it is not reasonably necessary, or that it is not related to your work injury. If the insurer declines to pay for your medical expenses they will need to provide written reasons in the form of a Section 78 Notice.

If the insurer declines treatment of medical expenses over the phone, make sure you ask them to provide a Section 78 Notice in writing outlining why they have declined your request. They must by law put the reasons for declining treatment in writing within 7 days.

It is important to obtain a Section 78 Notice as it is needed to challenge the decision of the insurer.

If the medical treatment dispute cannot be resolved and you consider the treatment to be reasonably necessary, you can make an application to the Personal Injury Commission to appoint an independent Member to hear and determine the dispute.

You will need medical evidence to support the argument that the treatment is “reasonably necessary”, you lawyer will obtain this evidence on your behalf.

If you wish to challenge the decision of an insurer, you should contact an Accredited Specialist in Personal Injury Law like Garling & Co. We can help you with your medical expenses claim, simply get in touch with us through the below;

1. Complete our FREE case assessment form HERE
2. Email us at
3. Give us a call on (02) 8518 1120