End of medical entitlements

Published: 12 August 2019
Last edited: 12 August 2019

This information does not apply to exempt workers

Workers whose weekly benefits have ceased are still entitled to claim for ongoing medical benefits for a set period of time. This entitlement period depends on their assessed level of permanent impairment, as detailed in the table below.

Eligibility criteria

Medical benefits entitlement period

Workers with no permanent impairment assessment, or permanent impairment assessed as 0-10%.

Two years from:

  • when weekly payments stop, or
  • from the date of claim if no weekly payments are made.

Workers with permanent impairment assessed as 11-20%.

Five years from:

  • when weekly payments stop, or
  • from the date of claim if no weekly payments are made.

Workers with high needs. This refers to workers:

  • with permanent impairment assessed as greater than 20%, or
  • where an approved medical specialist has declined to make an assessment as the worker has not reached maximum medical improvement, or
  • whose insurer is satisfied that the worker is likely to have permanent impairment of greater than 20%.

For life.

If a worker wishes to seek treatment after their weekly benefits have ended, the normal approval process applies unless the treatment is pre-approved. See 'Medical, hospital and rehabilitation'.

Lifetime entitlements

Some medical care and treatments are considered lifetime entitlements and are available to all workers for life.

These include home or vehicle modifications, crutches, artificial members, eyes or teeth, artificial aids or spectacles (including hearing aids and hearing aid batteries). Refer to 'Aids and modifications' for further information.

Secondary surgery is also included (see ‘Secondary surgery’ below).

Secondary surgery

Workers are entitled to make a claim for 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 of approval of the earlier surgery (or is approved later, following determination of a dispute that arose within that two years).

There is no time limit for the surgery to take place, however approval must be obtained from the insurer within two years from the date of the last surgery approval.

When secondary surgery is approved and undertaken, the worker is covered for all expenses that would normally be covered for surgery including:

  • medical costs
  • hospital costs
  • post-surgery treatment, and
  • weekly benefits for the period of incapacity following the surgery.

Notice

Insurers should provide written notice to the worker before the end of the compensation period for reasonably necessary medical treatment and services.

The worker’s nominated treating doctor and other treatment providers should also be informed, ensuring that they are aware that the compensation period for entitlements will end.

Information for medical providers can be found in the SIRA fact sheet Cessation of medical, hospital and rehabilitation expenses (Section 59A): Information for health providers.

S19. Section 59A notification
Principle
Workers whose medical benefits are due to cease will be provided with appropriate notice before the cessation of those benefits.

Support services

A worker may still require medical treatment once their entitlement to medical expenses cease. Medical and related treatment may be necessary to:

  • maintain wellbeing, as opposed to rehabilitation and/or return to work, or
  • develop appropriate strategies to ensure any specific or specialised dependency need (related to the injury and/or degree of permanent impairment) is supported.

In these circumstances, it is expected that insurers provide the necessary support, and determine where a worker can access services through the public/private system, helping them transition to it.

Insurers may also help workers, their immediate family and/or support network by connecting them to services offered by HSNet and Ability Links NSW.

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