Claiming for medical and like expenses in VictoriaPublished on Posted on
Please note that this post was written for Victorian audiences and the information within may not apply to other regions.
The WorkCover and TAC schemes in Victoria both provide “no fault” benefits to those injured with an accepted claim regardless of whose fault the injury or illness was.
Such benefits include:
- Payment of weekly compensation.
- Payment of medical and like expenses; and
- A lump sum for personal injury/permanent impairment.
Common law damages can only be claimed by injured parties where someone else is at fault.
What are “medical and like” expenses? What is included in “medical and like” expenses?
The medical and like expenses category covers a broad range of costs. Referring to medical services and treatments that are reasonable and related to the accident and injury in question.
As mentioned above, these entitlements are available irrespective of who at fault for the injury. Generally these continue for as long as you need the treatment.
Medical and like expenses can include:
- GP appointments.
- Hospital expenses.
- Surgery expenses.
- Rehabilitation expenses.
- Physical therapies including physiotherapy and other allied health services.
- Specialist appointments.
- Psychological/psychiatric therapy.
- Medication expenses.
- Personal and home help services such as cleaning, gardening and childcare assistance.
- Occupational rehabilitation services.
- Equipment aids including shower stools and walking aids.
- Radio-logical scans and other investigations.
- Travel expenses.
There are limits on claiming some expenses. For instance, you may only be entitled to a limited amount of cleaning or gardening services per fortnight.
How to make a claim for medical and like expenses
In order to make a request for a particular service or treatment, your treating doctor needs to write a letter to the insurer, whether that be your WorkCover insurer or the TAC, to ask them to fund the treatment.
It’s recommended that your doctor ensure they include the medical justification for the treatment, and, if there has been a gap since your last treatment, explain the reasons for that gap.
The insurer will use this information to decide on the merits of the request and either approve or deny it. The insurer may request further information before approving a service. In some cases, the insurer may require an assessment by a medicolegal assessor or an Occupational Therapist before approving a treatment or service request.
If they approve it, then you can arrange with your treatment provider to undergo the treatment, or with a service provider for the assistance you require.
Note: When it comes to a TAC claim, generally a medical excess applies before the TAC will start paying.
Who can perform treatment or services?
WorkCover insurers and TAC will only pay for treatment or services performed by providers that are registered with them.
If you are being referred for medical treatment, it is important for you to check that the medical treater you are being referred to is registered with WorkSafe or TAC. You can find this out by asking them if they are registered.
For services under WorkCover, there is a helpful search function for some service providers on the WorkSafe Injury Support Provider Search.
For claiming services for both WorkCover and TAC, you should make sure to ask whether a provider is registered with either WorkCover or TAC before engaging their services.
What medical and like expenses can’t be claimed
While there is a broad range of medical and like expenses you can claim, the list is not exhaustive – there are certain expenses that are not covered.
These may include expenses that are not deemed to be reasonable and necessary for the treatment of the injury, or expenses that are not directly related to the injuries suffered because of the specific work accident or transport accident.
Types of expenses that may not be covered include:
- Elective or cosmetic treatment such as plastic surgery
- Non-essential dental work.
- Experimental or unproven treatments.
- Complementary therapies.
- Over-the-counter medicines or supplements.
- Repairs or purchases of non-medical personal items.
WorkCover and TAC also often won’t cover treatment or services outside of Australia, by a person who isn’t registered, qualified, or authorised to provide the service or treatment, or services that are not safe or effective.
It’s important to note, however, that each WorkCover and TAC claim is evaluated on a case-by-case basis, and the specific expenses that are covered will depend on the circumstances of the injury.
For example, Zaparas Lawyers successfully helped our client who suffered life-changing injuries at work have her medicinal cannabis chronic pain treatment funded by WorkCover – something difficult to do for conditions not approved by the TGA.
What to do if your insurer denies a request for a medical and like expense
There is the possibility that a request for medical and related expenses is rejected, but don’t be discouraged if this happens to you because you have the right to appeal the decision.
Both WorkCover insurers and TAC have informal review procedures that you can access at first instance. However, these processes are conducted within each insurer without the intervention of an outside organisation.
If you go through an informal review process, you should provide as much information and evidence as possible to support your claim. This may include medical records, receipts and other documentation that demonstrates the need for it.
In the case of WorkCover claims, you are able to dispute a decision by making an Application for Conciliation to the Workplace Injury Commission. You must make an application within 60 days of receiving the WorkCover insurer’s decision.
For TAC claims, you have 12 months from the date of TAC’s decision to make a Dispute Resolution Application.
Additionally, if you are not successful in those processes, there are further appeal processes that you can access to dispute the insurer’s decision.
Dispute processes can be complex, so it’s recommended to seek legal advice or representation to ensure that your rights are protected throughout the process.
Additional helpful resources from Zaparas Lawyers: