If you have been injured at work and your claim has been accepted, you might be wondering what WorkCover will actually cover?
By law, WorkCover are obligated to pay for all work injury related medical and rehabilitation costs so long as they are considered necessary and reasonable
So what will WorkCover cover?
Typical examples of reasonable injury related treatment include:-
- Treatment by your GP
- Appointments with a treating specialist
- Physiotherapy sessions
- Hydrotherapy sessions
- Sessions with an exercise physiologist
- Acupuncture (so long as it is provided by a doctor, physiotherapist, or registered practitioner
- Counselling or psychology sessions
- Medical items (wound dressings, bandages, hearing devices)
- Medications (Note – WorkCover will not fund medicinal marijuana)
- Hire of medical aids and devices (crutches, wheelchair)
- Medical investigative procedures – MRI, ultrasound, x-rays
- Travel expenses
- Surgical procedures
What do I do if I my specialist is recommending surgery?
If you have been recommended for surgery, then provided that the surgery is to treat your work related injury (and not an aggravation of a pre-existing injury), WorkCover are obliged to fund the cost of the procedure, your hospital fees and any rehabilitation that you require post-procedure.
Your treating doctor will need to submit a formal request for surgery setting out your details, the nature of the procedure that is to be performed and answer a few short questions related to your expected timeframes to return to work. Once completed, your treating doctor will need to submit this form to WorkCover for their consideration which can be done online, by Provider Connect, or by fax.
In some cases, WorkCover may refer you to be assessed by an independent specialist to determine whether the surgical procedure is necessary and is needed to treat your work related injury.
It is important to be aware that most medical procedures have set fees and WorkCover will only pay up to the listed amount for that particular procedure. These costs are set out in the Medical Table of Costs and Allied Health Table of Costs.
If your doctor or treatment provider charges more than what is listed, you’ll need to pay the difference yourself (but keep a copy of your receipt, as the difference can often be claimed in any ensuing common law claim).
What are my options if WorkCover rejects the request for surgery?
If WorkCover is talking about rejecting your doctor’s request for surgery, it is important that you DO NOT ask WorkCover for written reasons for decision (although they may provide them to you without being asked).
If written reasons for decision have been provided, then your only avenue of appeal is to the Industrial Magistrate’s Court, which has to be lodged with the Court registry within 20 business days after you receive written notice stating the reasons for the decision.
This process is effectively like proceeding to a mini-trial. The expense that would be incurred in undertaking this exercise means that is it usually not worth pursuing, particularly if there is no guarantee of success and only limited legal fees are recoverable even if successful. The legal costs of the appeal hearing will often outweigh the medical costs of any proposed surgery.
If written reasons for decision have not, however, been provided, then you can try and obtain some further specialist medical evidence which supports the need for the surgery and then provide that to WorkCover to convince them that the need for the surgery has been caused by your work injury.
Other than appealing to the Industrial Magistrate’s Court, your only other options with respect to funding the surgery are usually:
- Receive assistance from your private health insurer (where applicable). N.B. In some cases, you can take out private health insurance, wait out the 12 month waiting period (for any pre-existing condition) and then fund the surgery that way;
- Receive assistance through the public health system (usually subject to a hospital waiting list); or
- Pay for the treatment yourself and include the cost of the surgical procedure and subsequent rehabilitation in your common law claim for damages. To determine whether this is a viable option for you, we would recommend speaking to one of our workplace injury experts at East Coast Injury Lawyers about whether you would be entitled to do this.
It is often difficult to have surgery approved and paid for by WorkCover in circumstances where most people of working age have some degree of (normal age related) degeneration in their spine, so it is important that you get legal advice that is tailored to your specific circumstances from an expert workers’ compensation personal injury lawyer as soon as you can after surgery has been recommended.
