Medical and related services

Aids and modifications

A worker may have an injury that requires an aid or modification to help them in their recovery or activities of daily living.

Aids may include:

• crutches, artificial members, eyes or teeth, and other artificial aids or spectacles
• any nursing, medicines, medical or surgical supplies, or curative apparatus, provided for the worker other than as hospital treatment.

A worker may need equipment to help with personal care (for example, a shower stool or long handled scrubber) or housekeeping (like a jar-opening aid). 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 injury. They can also pay the reasonably necessary costs of aids including purchase, hire, delivery, installation and maintenance.

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.

As in the case of other medical entitlements under section 60 of the Workers Compensation Act 1987 (1987 Act), when approving aids and modifications the insurer needs to consider whether:

• the aid or modification meets the definition of medical or related treatment described in section 59 of the 1987 Act
• the treatment or service is for the compensable injury
• the treatment or service is reasonably necessary (see ‘What is reasonably necessary?’).

Depending on the request, the insurer may need a further assessment or to obtain multiple quotes. They should consider the appropriate cost-benefit before engaging further assessment costs.

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 must 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 can be made to car modifications. If the vehicle is for the worker to drive, a medical clearance will also be required.

Hearing aids

A claim for hearing aids is a claim for medical expenses. In determining whether a hearing aid is reasonably necessary treatment, an insurer may consider:

• an Ear, Nose and Throat (ENT) specialist report, including audiogram, recommending the use of hearing aids
• a quote for the cost of the hearing aids completed by a SIRA-approved hearing service provider
• a completed worker's injury claim form.

If the ENT is a SIRA-approved hearing service provider, they can complete the hearing needs assessment and provide a quote for hearing aids.

If the ENT is not a SIRA-approved hearing service provider they will need to refer to a SIRA-approved hearing service provider for services in relation to the provision of hearing aids.

It is recommended that both the hearing needs assessment and quote include:

• a full description of the hearing aid recommended
• an outline of how the hearing aid will help the worker in overcoming the effect of the hearing impairment
• clinical rationale for the selected hearing aid
• the audiogram the recommendations are based on
• the hearing service provider details, including SIRA provider number
• full details of the costs of the hearing aids, including handling and fitting fee, in accordance with the relevant Fees Order.

The insurer should determine liability for a hearing aid claim within 21 days.

Information on eligibility to claim hearing aids and other compensation for hearing impairment can be found at 'Hearing impairment'.

Replacement and repair

Hearing aids are considered an ‘artificial aid’ and as such workers can make claims for replacement hearing aids, batteries and maintenance for life.

Batteries and maintenance are to be provided by SIRA-approved hearing service providers, and the worker will be required to sign and date any invoices submitted.

Requests for replacement hearing aids are to be supported by the worker’s nominated treating doctor, using the request for replacement hearing aid form.

Replacement hearing aids will be considered where:

• the hearing aid is lost or damaged and the loss or damage is not covered by warranty or insurance, or
• the worker’s hearing loss further deteriorates and the worker can no longer effectively communicate using the current hearing aid.

Claims for replacement hearing aids are to be determined within 21 days.

Lifetime entitlement to aids and modifications

Under section 59A(6) of the 1987 Act, workers have a lifetime 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 (see ‘Medical entitlements').

Fees and invoices

In most cases, the provider will forward an invoice directly to the insurer.

The provider is not permitted to directly bill the worker for services related to the claim.

There are no Fees Orders or Fees and practice requirements for aids or modifications other than for hearing providers (see below). The insurer should negotiate an appropriate fee prior to the approval of the aids or modifications taking into account what would be customarily paid in the community.

Invoices must include:

• the worker's first and last name, and claim number
• payee name, address, telephone number and email address
• payee Australian Business Number (ABN)
• name of the relevant service provider who delivered the relevant service
• in the case of approved hearing providers, the provider’s SIRA approval number
• relevant SIRA payment classification code (where applicable). Refer to the relevant Fees Order and the Workers Compensation Insurer Data Reporting Requirements
• service cost for each SIRA payment classification code and service duration (if applicable).
• the date of service
• the date of invoice (must be on the day of or after last date of service listed on the invoice)

To prevent delays in payment, these details need to be provided on all invoices.

Hearing providers

Fees for hearing aid providers and medical practitioners are set out in the relevant Fees Orders. The Fees Order specifies how much can be charged, any service restrictions and what codes providers are to use.

Fees Orders set the maximum amount payable per service and reiterate that workers are not liable for these costs.

No fees are payable for cancellation or non-attendances. Pre-payment of fees for reports or services is not permitted.