LawTalk Blog

Workers compensation; are your medical expenses being paid?

workers compensation and medical expenses

When people are injured at work, their primary concern involves whether or not the injury will impact on their ongoing employment, or whether they will continue to get paid during periods of recovery or periods when they need to remain at home because they cannot perform their pre-injury duties.

However, an equally important consideration for injured workers is whether their medical treatment is being paid for. Injured workers who have an “accepted workers compensation claim” should never be personally out of pocket for reasonable and necessary medical and like expenses as a result of treatment for their work related injury.

This might seem simple enough, but all too often we speak to clients who are upset and frustrated because they have been told by their workers compensation Case Manager that they won’t support payment of specific medical expenses. Case managers may also conclude that the worker has had enough treatment (for example, the Case Manager might conclude that the worker has already had 6 sessions of physiotherapy for their back injury and reach a conclusion that surely that is enough!), even if the worker believes that they need more treatment, and the treatment is beneficial.

Remember, Case Managers are not doctors and incorrect decisions made about your medical treatment may severely impact your ability to fully recover. Bad decisions by Case Managers about medical treatment can even lead to a worsening/aggravation of the initial injury.

Injured workers who get told that they are no longer entitled to receive payments for treatment, or do not have their medical expenses reimbursed often choose to go without much needed medical treatment because of this "advice" from the Case Manager. Many of these injured workers who are often already struggling financially because of the reduction in income following their injury cannot afford to pay for treatment and medication themselves without the support of the Case Manager.

If you face this dilemma, seek urgent legal advice because you do not need to accept the decision of your Case Manager and you can choose to dispute their decision through the South Australian Employment Tribunal. Sometimes just the mention of a legal challenge is enough for the Case Manager to reassess their initial position.

If you have an accepted workers compensation claim then the Case Manager is legally obliged to pay all reasonable and necessary medical expenses that you incur as a result of your work related injury. Often what is ‘reasonable and necessary’ can be complicated. For example, different doctors might not agree that a particularly type of medical treatment is best for the injured worker. A worker’s doctor might indicate that surgery is absolutely necessary, but the doctor chosen by the Case Manager might prefer more conservative treatment. This can create complicated and very frustrating legal difficulties.

Sometimes doctors or other medical professionals want pre-approval for the costs of surgery or other major treatment (because they won't proceed without this treatment until they have approval). For example, if shoulder surgery is going to cost $6,000, the surgeon will want a guarantee from the Case Manager that the surgery will be paid for before they perform the surgery. The Return to Work laws compel a Case Manager to make a decision about whether or not they will approve surgery, and if the worker is dissatisfied with the decision, again this should be disputed.

To summarise, injured workers are entitled to receive reasonable and necessary medical treatment and the insurer is obliged to pay for that treatment. If your medical expenses are not being paid by your Case Manager or you are encountering other problems with the way your workers compensation claim has been handled, feel free to contact the writer of this blog directly.

Please note, this Blog is posted in Adelaide, South Australia by Andersons Solicitors. It relates to South Australian legislation. Andersons Solicitors is a medium sized law firm servicing metropolitan Adelaide and regional South Australia across all areas of law for individuals and businesses.

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