WorkCover reasonable medical and like expenses

Amongst other benefits like weekly payments and lump sum compensation, an injured worker is also entitled to medical and like expenses as part of their Victorian WorkCover claim. But what are medical and “like” expenses? Medical refers to expenses for treatment by doctors, physicians and other healthcare professionals. “Like” refers to expenses for support and other recovery assistance required by an injured worker, other than medical treatment.

You can claim medical expenses for any medical treatment you require as recommended by your doctors, as long as it is reasonable and relates to your work injury.

Medical expenses can include:

• medication;
• hospital visits;
• nursing care;
• consultations with a general practitioner;
• consultations with a psychologist or psychiatrist;
• physiotherapy treatment;
• chiropractic treatment;
• osteopathy treatment;
• surgery;
• pain management; and
• any other medical services you require as recommended by a medical practitioner.

The medical expenses you claim will depend on what services and treatment are recommended to you by your medical practitioner.

You can claim “like” expenses for services that you require to facilitate and assist in your recovery, other than medical expenses. These expenses must also be of a reasonable cost and relate to your work injury.

“Like” expenses can include:

• gym and swimming memberships;
• home help with cleaning and/or gardening;
• modifications to your home;
• remedial massage;
• travel expenses; and
• equipment.

This is not an exhaustive list and can include other recovery assistance services tailored to your needs and as recommended by your medical practitioner.

These expenses are intended to assist injured workers in managing their activities of daily living such as cleaning, gardening, travelling, grooming etc.

The “like” expenses you claim will depend on what support services you require on an individual level and whether your medical doctor supports your need for these services.

Domestic help

If you need help with cleaning your house or mowing the lawns, you can request that the WorkCover insurer fund these support services. If you have pets and are unable to take them out for a walk and there is no one at your home that can do so, you may be able to claim the cost of a professional dog walker. Often the WorkCover insurer is reluctant to accept paying for home help where you live with another person in the home that can attend to these activities for you.

Travel expenses

Travelling expenses can include payment for taxis to take you to your medical appointments if you cannot drive. If you are driving to these medical appointments, you can claim the mileage travelled from your home to the appointment and back.

Modifications to your home or car

In circumstances where you are unable to attend to your personal grooming and hygiene and you require a change to your home to allow you to conduct these activities safely, you may be entitled to request a modification to your home such as a ramp at the front of the house. You may also be entitled to modifications to your car to assist you in driving where your work-related injury affects your ability to drive.

Equipment expenses

If you have restricted mobility because of your work-related injury, you may be able to claim a wheelchair or other type of equipment to assist you with your mobility. You may be able to claim a shower chair or other equipment that you require in the home to assist you with these activities.

In order to request medical expenses, you must see your doctor who manages your treatment and submit a request to your WorkCover insurer for the particular treatment recommended. Your doctor will also be required to provide supporting medical evidence for the requested treatment.

The supporting medical evidence must detail:

• the specific procedure or treatment;
• the need for the specific procedure or treatment;
• the relationship of the treatment to your work-related injury;
• a proposed date as to when the procedure or treatment will be provided; and
• the cost of the treatment or service with the appropriate billing item codes, as required by WorkCover.

It is best practice to obtain an approval for medical expenses before they are incurred.

When a request for medical expenses has been received by the WorkCover insurer, they have about 10 days to respond to that request.

The WorkCover insurer can either approve or reject your claim, or request further information. A request for further information can be, for example, arranging for you to see an independent medical examiner or requesting further records from your medical practitioners.

When considering whether a medical expense is reasonable, the WorkCover insurer considers:

• whether the medical provider is registered with WorkCover;
• the necessity of the service to treat your injuries;
• the clinical justification for the treatment recommended;
• the benefit to the worker of the treatment; and
• the cost of the treatment.

Similar to requesting medical expenses, you must see your medical doctor and ask them about your support service needs. Your doctor must submit a request to your WorkCover insurer for the particular service recommended.

You should also contact your WorkCover insurer to discuss your support service needs and why you believe you require these services to complete necessary activities of daily living.

The WorkCover insurer may arrange for an occupational therapist to attend your home and assess your needs.

For gym and swim memberships or ongoing physical therapies, it is recommended that you obtain a request or referral from your physiotherapist, chiropractor or osteopath. You can also obtain referrals for these services from your general practitioner.

If the WorkCover insurer declines to pay for any medical and “like” expenses, you should obtain a copy of that decision, in writing, from your case manager.

You have the right to challenge these decisions at the Accident Compensation Conciliation Service, now Workplace Injury Commission, within 60 days of that decision.

Unlike WorkCover weekly payments, there is no legally enforced cut off point for your medical and like expenses entitlements.

The WorkCover insurer will regularly review the expenses being paid to you to ensure that it continues to meet the requirements of reasonableness, necessity and relationship with your work-related injury.

Even if you receive lump sum compensation, your entitlement to medical and “like” expenses should continue for as long as it is required and provided that the requirements are met.

The longer it has been since your injury, the more difficult it will become to seek medical expenses where the relationship with your work-related injury becomes more distant. However, your entitlement does not cease under the legislation. You should seek legal advice if WorkCover ceases payment of your medical and like expenses and you believe you still require these services.

In the case of a self-insurer, for example Crown or Qantas, often when resolving a claim for lump sum compensation under common law, they also cease your entitlement to medical and like expenses. This cessation of medical expenses must be considered before signing any settlement release.

In circumstances where you have already incurred the medical expense, you can seek a reimbursement from the WorkCover insurer. You must provide the insurer with a copy of your receipt or invoice for the medical or “like” expense that you incurred.

The insurer must review your request for reimbursement and provided that the medical treatment or “like” expense has been approved, you should receive that reimbursement to your nominated bank account.

If you do not have an approval, the WorkCover insurer must first review the request and decide whether they are willing to approve it or not. They will review the request by considering the requirements of reasonableness, necessity and relationship with your work-related injury. After the review, they will either approve and reimburse you or reject and not reimburse you.

If rejected, you can also dispute this at the Workplace Injury Commission for conciliation.

You may not receive a full reimbursement depending on the cost of the service. WorkCover has set maximum fees payable for different services.

If your reimbursement exceeds the maximum fee payable for that particular service, you will only receive the maximum amount and you will have to bear the gap cost for that treatment. If you have a private health insurer, you can claim the gap cost from them.

In order to avoid this issue, it is recommended that you obtain approval from the WorkCover insurer before incurring the expense and also selecting providers that are registered for WorkCover. Providers registered with WorkCover will often charge within the WorkCover fees so that you do not have to pay any gap costs.

You can view WorkCover’s fee schedule on the WorkCover website here.

In exceptional circumstances, a medical provider may request from WorkCover to be paid above the scheduled rates. This is often for injuries that require complex medical specialities or for remote workers with limited access to medical providers.

The WorkCover insurer will consider whether the worker was genuinely unaware of the schedule of fees and also whether it is necessary and appropriate in the worker’s individual circumstances to pay above scheduled rates.

If you are having any trouble accessing your medical and “like” entitlements after a workplace injury and would like assistance, a member of our team would be happy to help you navigate the WorkCover process and get the most out of your entitlements.