GN 6.7 Aids and modifications
Published: 12 August 2019
Last edited: 12 August 2019
Application: This guidance applies to exempt workers
Overview
A worker may have an injury that requires an aid or modification to help them in their recovery or activities of daily living.
This guidance assists insurers in understanding what aids and modifications may be compensable under a workers compensation claim, as well as the process for approval, invoicing and payment.
What are aids and modifications?
Aids may include:
- crutches, artificial members, eyes or teeth, and other artificial aids or spectacles
- any nursing medical or surgical supplies, or curative apparatus, provided for the worker other than as hospital treatment.
Modifications include those made to a worker’s home or vehicle (as directed by a medical practitioner) due to the nature of the worker’s incapacity - see section 59 of the Workers Compensation Act 1987 (1987 Act).
A worker may need equipment to help with personal care (for example, a shower stool or long handled scrubber), housekeeping (like a jar-opening aid), or performing work duties (for example, an ergonomic chair or orthotics in their shoes). Modifications may also be required for a worker’s car or house (for example, a ramp for a wheelchair or a railing in the bathroom).
Insurers can pay the costs for reasonably necessary modifications, where the modifications are required as a result of the work injury. They can also pay the reasonably necessary costs of aids including purchase, hire, delivery, installation and maintenance.
Pacific National Pty Ltd v Baldacchino [2018] NSWCA 281
The worker suffered a compensable left knee injury in October 1999. He underwent left knee surgery in December 1999. In 2016, the worker was recommended to undergo total knee replacement surgery by his orthopaedic surgeon. The insurer disputed liability, and the worker commenced proceedings in the Commission.
The Commission determined that the total knee replacement surgery was reasonably necessary medical treatment that was not caught by the time limitations in section 59A(1) and (2) of the 1987 Act.
The employer appealed and in its decision the Court of Appeal confirmed that the knee replacement surgery was reasonably necessary medical treatment as a result of the injury, as it was not caught by the time limitations contained in section 59A(1) and (2) of the 1987 Act and was within the scope of the ‘provision of … other artificial aids’ pursuant to section 59A(6)(a). At paragraph [29], Macfarlan JA said:
'artificial aids' must, as the appellant submits, work to ameliorate the effect of a person’s disability and may comprise a single object or a composite of objects operating together… a knee replacement has these characteristics. According to the parties’ agreement, during the surgery the ends of the femur and the tibia are replaced with an introduced material and a piece of plastic is inserted between the bones as reconstructed. Plainly these materials are designed to facilitate the movement and use of the knee after the operation, therefore easing the patient’s disability. Their 'provision' (see s 59A(6)(a)) cannot occur without a surgical operation. The cost of the operation therefore falls within the statutory provision.
Macfarlan JA considered the cost of the surgery was a cost of the provision of a total knee replacement because it ‘requires surgery’. He commented (at [42]):
I should not be taken to be adopting a general rule that the cost of surgery is always the cost of '[t]he provision of … artificial aids', as there may be many cases where the insertion of material into a person’s body is only an incidental part of major surgery. Each case must be decided on its own facts.
Approval of aids and modifications
Insurer pre-approval is required for aids and modifications. A request for aids and modifications may come from the nominated treating doctor, the treating specialist, allied health practitioner or rehabilitation provider.
Just as in the case of other entitlements under section 60 of the 1987 Act, when approving aids and modifications, the insurer needs to consider whether:
- the aid or modification meets the definitions described in section 59 of the 1987 Act
- the treatment or service is for the compensable injury
- the treatment or service is reasonably necessary.
The principles of ‘reasonably necessary’ should be applied when approving aids and modifications. Depending on the request, the insurer may need a further assessment or to obtain multiple quotes. See Part 4.2 of the Workers compensation guidelines (the Guidelines) and Insurer guidance GN 6.1 Determining liability for medical and related treatment for more information on determining whether medical or related treatment, as defined by section 59 of the 1987 Act, is reasonably necessary.
Note: The provision of aids and modifications can have a significant impact on a worker’s recovery and requests should be followed-up promptly. A decision must be made within 21 days.
Home modifications
Proof of ownership of the home or the landlord’s written permission should be shown before the insurer can consider home modifications.
Car modifications
The worker must be able to demonstrate a current driver’s licence and proof of ownership of the car before consideration will be made to car modifications. If the vehicle is for the worker to drive, a medical clearance will also be required.
Lifetime entitlement to aids and modifications
Under section 59A(6) of the 1987 Act, workers have no limits on entitlement to the provision of aids and modifications to their home or vehicle to help them with their work-related injury.
Nursing, medicines, medical or surgical supplies or curative apparatus, supplied or provided for the worker other than as hospital treatment are limited by the compensation period.
Invoicing and payment
Invoices should meet SIRA invoicing requirements and should be submitted to the insurer within 30 calendar days of the treatment/service (see Insurer guidance GN 4.3 Invoices and reimbursements).
Working toward best practice
Insurers should call the practitioner if they have questions regarding an invoice. Errors or queries can often be resolved quickly over the phone, and this is beneficial to all parties. If telephone contact is unsuccessful, then an email or letter should be sent seeking clarification.
Insurers should always attempt to resolve an issue rather than just not pay an invoice. Non-payment of an invoice can be detrimental to the insurer-health practitioner relationship, and negatively impact the worker’s recovery.
Insurers are to pay provider invoices promptly. Prompt payment is considered to be within ten calendar days or the provider’s specified business terms, whichever is later. It is preferable that payments to providers are made by Electronic Funds Transfer (EFT).
Related: Legislation and regulations
Related: Guidelines and standards
Related: Insurer guidance
Contact SIRA
Phone 13 10 50
Email [email protected]