Workers' Compensation Claims Pre-Approval from the Insurer for Treatment

23-10-2019    |    Resource

If you have been hurt at work, then your employer must pay all your reasonable treatment expenses for your injury. (Section 60(1) of the Workers' Compensation Act 1987[The Act]). This treatment includes hospital treatment, ambulance services, and workplace rehabilitation amongst many other treatment services.

Prior approval to undergo some treatment from the Workers Compensation Insurer may be required before your employer is liable for some treatment.  (Section 60(2A) of the Act).  However, on 1 January this year new Workers Compensation Guidelines were introduced for handling of all claims whether your injury occurred after that date or before that date.  All employers in New South Wales and the insurers must comply with these guidelines.

Those guidelines (Table 4.2 of the Guidelines is headed "Other treatment and services available without pre-approval from the Insurer".) give power to the Workers' Compensation Commission to order an employer or its insurer to pay for treatment even if pre approval was not obtained from the insurer.   The Workers Compensation Commission will make that order if it is satisfied the need for the treatment was caused by the injury at work and if it is reasonable and necessary.

The Guidelines appear to override the requirements of the Act to obtain prior approval to undergo the treatment.  So, if you have undergone treatment and you or your treating medical practitioner did not obtain prior approval from your employer's Workers Compensation Insurer it does not mean you cannot recover the costs of that treatment.

In our experience, injured workers are routinely advised by Claims Officers who deal with Workers' Compensation Claims that treatment expenses cannot be paid because there was no prior approval.  In that case the Insurer must give the worker a notice if it is denying liability to pay the treatment (Section 78 of the Workplace Injury Management Act 1998 [S.78 Notice])

So if a Workers Compensation Insurer says it will not pay for your treatment because you did not obtain prior approval or you receive a "S.78 Notice" you should immediately seek legal advice from a law society accredited specialist in Person Injury as the lack of prior approval is not fatal to any claim for treatment expenses, and in particular surgery, if the cost of the treatment was reasonable and necessary and caused by the work injury, at the time that it was incurred.

You should not accept any adverse decision regarding treatment expenses, or payment of benefits generally, without seeking legal advice.  Lamrocks can assist injured workers in relation to these issues.  Lamrocks has solicitors who are Accredited by the Law Society as Specialists in Personal Injury Law.

Those specialists have also been approved by the WorkCover Independent Review Office (WIRO) to provide legal assistance to workers injured in the course of their employment. A Grant of Legal Aid can be obtained from WIRO to dispute adverse decisions by Insurers regarding Workers' Compensation claims.  The dispute can be taken to the Workers' Compensation Commission to determine, at no cost to you.

Please contact us if you wish to consult with one of our Law Society Accredited Specialists in Person Injury Law.

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