The number of injured workers involved in disputes with icare and their employer regarding payment of medical treatment is on the increase.
Medical and related treatment includes treatment by a medical practitioner, dentist, physiotherapist, chiropractor, osteopath, masseur and speech therapist. It is also defined to include the provision of crutches, glasses and other artificial aids (such as joint replacements), medications, domestic assistance and modification to an injured worker’s home or vehicle.
An employer must pay for any treatment if “it is reasonably necessary”.
Icare guidelines state that the following are to be taken into account in determining whether medical treatment is “reasonably necessary”:
- the appropriateness of the particular treatment
- the availability of alternative treatment
- the cost of the treatment
- the actual or potential effectiveness of the treatment
- the acceptance of the treatment by medical experts.
An injured worker’s treating medical practitioner will normally provide a report commenting on these factors. For example, a treating Neurosurgeon, who has recommended an injured worker undergo back surgery, may be able to comment that the surgery is appropriate given the other treatment options the injured worker has explored to date, that he / she is willing to perform the surgery, provide a quote, provide an opinion as to the likelihood the surgery will be effective, and comment broadly on the surgery’s acceptance by medical experts as a suitable treatment for the injury.
If icare and the employer continue to dispute that treatment is “reasonably necessary”, proceedings can be commenced in the Personal Injury Commission. It has been determined that the following five factors are relevant to the determination of whether medical treatment is reasonably necessary:
- Prima facie, if the treatment falls within the definition of medical treatment it is relevant medical treatment. Broadly then, treatment is given by, or at the direction of, a medical practitioner and is such treatment;
- However, though falling within that ambit and thereby presumed reasonable, that presumption is rebuttable if it be shown that particular treatment afforded is not appropriate, is not competent to alleviate the effects of injury, then it is not relevant treatment for the purposes of the act;
- Any necessity for relevant treatment results from the injury where its purpose and potential effect is to alleviate the consequences of the injury;
- It is reasonably necessary that such treatment be afforded a worker if the Commission concludes, exercising prudence, sound judgment and good sense, that it is so. That involves the Commission in deciding, on the facts as it shows them, that the particular treatment is essential to, should be afforded to, and should not before born, by the worker;
- In so doing the Commission will have regard to the medical opinion as to the relevance and appropriateness of the particular treatment, any available alternative treatment, the cost factor, the actual or potential effect of this of the treatment and its place in the usual medical armoury of treatments for the particular condition.
Commencing proceedings in the Personal Injury Commission is required when Insurer’s decline to pay for physiotherapy, medication, surgery, or other medical or related treatment. Although unfortunate, this often occurs, despite evidence that an injured worker’s treating medical practitioner has recommended the treatment to achieve the best outcome for the worker.
As an injured worker you are entitled to be advised by Toby Tancred. The Independent Review Office (IRO) can assist by providing funding for this legal advice. IRO provides funding to approved Solicitors to investigate claims, provide advice to you as an injured worker, and deal with employers and insurers on your behalf. Toby is an IRO Approved Lawyer. Toby Tancred is a Law Society Personal Injury Accredited Specialist and has been recognised by Doyle’s Guide as a Recommended Work Injury Compensation Lawyer for two years running. Doyle’s Guide has also named Toby Tancred Solicitor as a Recommended Asbestos & Dust Diseases Compensation Law Firm. Toby Tancred has the experience, knowledge and ability to help all injured workers in difficult times.