5.5.8.3 Reimburse DES-DMS payment to a worker

A worker may be entitled to reimbursement of the amount paid to the DES-DMS if the worker has a current entitlement to medical and like services.

For example A worker may not have a current entitlement to medical and like services if their entitlement has ceased because 52 weeks have elapsed since their entitlement to weekly payments ceased. A worker who receives a settlement A lump sum payment that replaces an injured worker's right to ongoing weekly compensation. or award of economic loss damages or a voluntary settlement of weekly payments, will continue to be entitled to receive medical and like services, subject to the legislation.

If a worker request reimbursement for the cost of the VRS Vocational Rehabilitation Services program, the Agent needs to determine whether the VRS program in full or part comprises services or items that might be payable as compensation under the definition of Occupational Rehabilitation Services, Personal and Household services or Medical and Like Services.

If the Agent does not have sufficient information to determine this, the worker should be encouraged to contact the VRS program provider and request a copy of their complete file or to make a request under the Freedom of Information Act 1982 to obtain a copy.

If it is determined that the services or items within the VRS program are claimable then the Agent is required to assess whether:

• these services or items are reasonable and/or necessary in the circumstances
• the costs of the services or items are reasonable.

Any VRS program items or services that are not reasonable and/or necessary or do not fall under the category of personal and household services, occupational rehabilitation services of medical services should not be reimbursed.

Agent decision is to reimburse worker

Where the Agent decides to reimburse the worker for the costs of all or part of the rehabilitation services provided, the Agent needs to advise the worker in writing that they will be reimbursing for part or all of the costs of the VRS program deducted from the lump sum, impairment benefit or common law damages payment received by the worker.

When reimbursing the costs of the VRS program from the lump sum, Agents must enter payment details following certain procedures.

Agent decision not to reimburse worker

If the worker’s request for reimbursement is denied in full, the Agent needs to advise the worker in writing.

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