S13. Additional or consequential medical conditions

Commencement date: 21 October 2019

It is important that prompt and proactive consideration is given to the development of additional or consequential medical conditions to ensure workers continue to receive appropriate compensation and support.

Principle

Prompt action will be taken to assess and address any additional or consequential medical condition identified on a certificate of capacity.

ExpectationsBenchmarks
S13.1When an insurer receives a certificate of capacity that identifies an additional or consequential medical condition not previously diagnosed or reported, the insurer is to seek advice from the treating doctor to establish the reason for inclusion on the certificate of the additional or consequential condition.

Advice sought within five working days after receipt of certificate

S13.2If the treating doctor considers that the additional or consequential medical condition may result from the compensable injury, the insurer is to contact the worker to establish whether they intend to make a claim for reasonably necessary treatment for the condition.

Contact with the worker attempted within five working days after receipt of certificate

S13.3

If the worker makes a claim for treatment or weekly benefits for the additional or consequential medical condition, the insurer is to make a liability decision.

Liability decision made within 21 days of lodgement of the claim

S13.4

If the worker is not making a claim for treatment or weekly benefits for the additional or consequential medical condition, this is to be documented on the claim file.

Evidence on claim file

It is important that prompt and proactive consideration is given to the development of additional or consequential medical conditions to ensure workers continue to receive appropriate compensation and support.

As claims progress, it is not uncommon for additional medical conditions or consequential conditions to be added to a certificate of capacity. This may have an impact on the management of a claim including the need for treatment, and the worker’s degree of permanent impairment. Insurers should be proactive in their review of certificates of capacity.

If the additional medical condition or consequential condition is accompanied by a request for treatment, the insurer must make a liability decision within 21 calendar days to determine if the employer is liable for costs and expenses related to the condition.

Insurers need to be aware of any medical condition which may impact a worker’s recovery at/return to work, whether work-related or not.

Properly responding to additional information on the certificate of capacity confirms to the worker and nominated treating doctor that requests for reasonably necessary treatment will be considered without delay.

If the additional or consequential medical condition is not work-related, prompt action by the insurer enables the treating doctor to appropriately manage the non-work-related medical condition.

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