Claims and injury management

Overview

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.

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:

Medical, hospital and rehabilitation expenses provided during the compensation period must still meet requirements that treatment and services:

• meet the definitions in section 59 of the 1987 Act
• are '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
• are 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).

Exempt workers

Note: There is no explicit 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, 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 the modification of a worker's home or vehicle, the provision of crutches, artificial members, eyes or teeth and other artificial aids or spectacles (including hearing aids and hearing aid batteries) and secondary surgery - section 59A(6) 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 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 will vary. Considerations for insurers include:

• length of time on workers compensation benefits
• type and frequency of ongoing treatment
• 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

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.

Disability support

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:

Lifeline

Lifeline provides access to crisis support, suicide prevention and mental health support services 24 hours a day, seven days a week. Call 13 11 14 or visit the website.

Beyond Blue

Beyond Blue offers support services 24 hours a day, seven days a week. They provide online tools and information to help manage stressful situations. Call 1300 224 636 or visit the website.

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.

MensLine Australia

MensLine Australia is a telephone and online counselling service for men with family and relationship concerns. Call 1300 789 978 or visit the website.

Emergencies

In an emergency, call 000 or the worker should go to their local hospital emergency department.

Secondary surgery

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 is entitled to weekly compensation 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 payments during the incapacity as they are outside of the second entitlement period, they are entitled to receive special weekly payments of compensation (special 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.