- GN 3.1 Initial notification of injury
- GN 3.2 Initial liability decision - provisional, reasonable excuse or full liability
- GN 3.3 Certificate of capacity
- GN 3.4 Pre-approval of treatment
- GN 3.5 Injury management plans
- GN 3.6 Investigating changes in capacity
- GN 3.7 Case conferencing
- GN 3.8 Rehabilitation services during case management
- GN 3.9 Work capacity assessments and decisions
- GN 3.10 Section 39 notification
- GN 3.11 Section 59A
- GN 3.12 Surveillance
- GN 3.13 Factual investigations
- GN 5.1A Calculating PIAWE
- GN 5.1 Calculating PIAWE for workers injured before 21 October 2019
- GN 5.2A Calculating weekly payments
- GN 5.2 Calculating weekly payments for workers injured before 21 October 2019
- GN 5.3 Making weekly payments
- GN 5.4 Weekly payments after the second entitlement period
- GN 5.5 Payments to workers with highest needs
- GN 5.6 Weekly payments for exempt workers
- GN 5.7 Permanent impairment
- GN 5.8 Property damage
- GN 5.9 Domestic assistance
- GN 5.10 Commutations
- GN 5.11 Compensation and other work entitlements
- GN 5.12 Death claims
- GN 6.1 Determining liability for medical and related treatment
- GN 6.2 Surgery
- GN 6.3 Nominated treating doctor and specialists
- GN 6.4 Allied health practitioners
- GN 6.5 Independent consultants
- GN 6.6 Referral to an injury management consultant
- GN 6.7 Aids and modifications
- GN 6.8 Independent medical examinations
GN 3.11 Section 59A
Application: This guidance does not apply to exempt workers
Under section 59A of the Workers Compensation Act 1987 (1987 Act), workers are entitled to either two or five years of reasonably necessary medical treatment and services after the date the worker’s weekly payments stop being payable or after the date their claim was first made, whichever is the later.
The period for which a worker has an entitlement to treatment and services is determined by the worker's degree of permanent impairment, as assessed.
The insurer should communicate regularly with the worker, employer and stakeholders regarding the worker’s entitlements. This should occur through the life of the claim. This includes providing early notification prior to the cessation of entitlement for medical treatment and services.
This guidance considers how section 59A operates.
Limit on payment of compensation
Workers whose weekly benefits have ceased, or who have never received weekly benefits, are entitled to claim for ongoing medical benefits for a set period of time.
This compensation period depends on the worker’s assessed degree of permanent impairment and is detailed in the table below:
Workers with no permanent impairment or a degree of permanent impairment assessed as 0-10%.
Two years from:
Workers with a degree of permanent impairment assessed as 11-20%.
Five years from:
Workers with high needs (see section 32A of the 1987 Act). This refers to workers:
Workers with highest needs (see section 32A of the 1987 Act). This refers to workers:
Medical, hospital and rehabilitation expenses provided during the compensation period must still meet requirements that treatment and services:
- meet the definitions described in section 59 of the 1987 Act
- is 'reasonably necessary' as a result of the injury (section 60 of the 1987 Act) - see Insurer guidance GN 6.1 Determining liability for medical and related treatment for more information on reasonably necessary
- is pre-approved by the insurer, unless the treatment of service is exempt from pre-approval, see Part 4.1 of the Workers compensation guidelines (Guidelines).
Note: There is no requirement for exempt workers to seek pre-approval for treatment, however exempt workers should be made aware that treatment and services may not be payable without insurer approval.
Payment of treatment and services for exempt workers must be assessed based on whether the treatment or service is required as a result of the injury and is considered reasonably necessary and on the provision of properly verified costs.
Exceptions to the limit on entitlements
Some medical care and treatments have no time limits. These include home or vehicle modifications, crutches, artificial members, eyes or teeth, artificial aids or spectacles (including hearing aids and hearing aid batteries) and secondary surgery - section 59A(7) of the 1987 Act.
Cessation of entitlements
Insurers should commence planning well in advance of the cessation of a worker’s entitlement to medical, hospital and rehabilitation benefits under section 59A of the 1987 Act. This will ensure the appropriate support is identified and, where required, provided to workers in a timely manner.
Insurers should ensure that the cessation date is taken into consideration when approving treatment in the period leading up to cessation.
Notification prior to cessation of benefits
Insurers are responsible for informing workers of their entitlements from when the claim is first received and on an ongoing basis through key case management review points.
Insurers should inform the worker well in advance of the cessation of their entitlement to medical benefits. Initially this can be a verbal discussion, followed by written notification to the worker and their nominated treating doctor at least 13 weeks before the cessation of their benefits in accordance with Standard of practice S19. Section 59A notification.
The written notification should include:
- the date on which compensation for reasonably necessary medical treatment and services is due to cease, and
- in the case of the worker, who to contact for further information.
Insurer support prior to cessation of medical benefits
The level of support a worker may require in the period of time leading up to expiration of their compensation period depends on a number of factors.
Considerations for insurers include:
- length of time on workers compensation benefits
- type and frequency of ongoing treatment (if any)
- type and dosage of medication (prescription and otherwise)
- worker’s relevant personal circumstances that the case manager may be aware of.
Depending on the worker’s individual circumstances, the insurer may need to contact the nominated treating doctor, or other treatment providers, to discuss the assistance they can provide the worker before their entitlement to medical benefits end. This might mean they talk with the worker about:
- other treatment or support services that may be of benefit prior to their entitlements ceasing (including potentially initiating a referral to another service)
- preparing a discharge plan with the goal of developing self-management strategies to promote independence from health care and to assist them with longer-term management of their injury/condition,
- the medical and/or support services available to them (and refer where appropriate) through publicly funded community, State or Commonwealth systems, or where applicable, private health insurer funded services.
Depending on the worker’s individual circumstances, the insurer may need to make the worker aware of the following services:
HSNet (Human Service Network) is a NSW public service directory that provides information across a range of supports from early intervention to crisis services in education, health, homelessness, and child and family sectors.
Ability Links NSW
Ability Links NSW is a free program to help people with disabilities (aged up to 64 years), their carers and families.
'Linkers' work closely with clients to provide short-term support that achieves particular outcomes. For example, a worker may want to participate in sport, education, volunteering, or other activities.
National Disability Insurance Scheme
The National Disability Insurance Scheme (NDIS) provides community links and individualised support for people with permanent and significant disability, as well as their families and carers. Call 1800 800 110 or visit the website.
Vulnerable or high-risk workers
The pending cessation of medical benefits may be quite stressful or daunting for some workers. Insurers should be aware of, and may need to make workers aware of support services including the following:
Mental Health Line
Anyone with a mental health issue can call and speak with a mental health professional 24 hours a day, seven days a week. Mental Health Line can also help the worker find local treatment options. Call 1800 011 511.
If the worker is experiencing acute mental health issues, they should contact the Mental Health Crisis Team in their local area.
In an emergency, call 000 or the worker should go to their local hospital emergency department.
Surgery is secondary surgery if:
- the surgery is directly consequential on earlier surgery and affects a part of the body affected by the earlier surgery, and
- the surgery is approved by the insurer within two years after the earlier surgery was approved (or is approved later than that following the determination of a dispute that arose within that two years).
Secondary surgery does not have to be undergone in the two-year period following the previous surgery, but it does need to have been approved by the insurer in that period of time.
When the worker is planning to undergo the secondary surgery pre-approval from the insurer is still required.
If the worker requires weekly benefits following secondary surgery, the worker can also access medical entitlements in respect of any treatment, service or assistance given or provided during the period in which weekly payments are payable (pending normal approval requirements) - section 59A(3) of the 1987 Act.
If a worker requires secondary surgery, but is not entitled to weekly benefits during the incapacity as they are outside of the second entitlement period, they are entitled to receive special weekly benefit compensation under section 41 of the 1987 Act, at the rate prescribed by section 37 of the 1987 Act.
In order for this compensation to be payable, the worker:
- must have received weekly payments of compensation in respect of the initial injury, and have had current work capacity prior to suffering the incapacity resulting from the injury-related surgery
- must have returned to work after the initial injury (whether in self-employment or other employment) for a period of not less than 15 hours per week, and have been in receipt of current weekly earnings (or current weekly earnings together with a deductible amount) of at least $155 per week.
This compensation is not payable for any period of incapacity that occurs:
- during the first 13 consecutive weeks after the end of the second entitlement period, or
- more than 13 weeks after the surgery concerned, or
- during any period for which the worker is otherwise entitled to compensation after the second entitlement period. See section 38 of the 1987 Act.