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4.3.5 Determining ongoing entitlement

Compensation for medical and like services (medical and like benefits) will cease to be paid:

• 52 weeks after a worker’s entitlement to weekly payments ceases, unless exceptions apply;

• 52 weeks after a worker’s entitlement to medical and like services arises, where a worker’s claim was accepted for medical and like services only, unless exceptions apply; or

• 13 weeks from the date a worker became entitled to provisional payments, where a worker’s mental injury claim was rejected.

52 week Medical and Like Entitlement Review (MLER)

When a claim has reached 52 weeks post:

• the entitlement to weekly payments ceasing (full-time Full-time worker means a worker who is employed for at least the normal number of hours fixed in any industrial award applicable to the worker or if there is no applicable award the prescribed number of hours return to work, certificate of capacity Ongoing certificate is issued for up to 28 days and can be issued by a: medical practitioner, osteopath, physiotherapist, chiropractor. reflecting capacity for pre-injury employment (1) In this Part — pre-injury employment means the employment of a worker in a position which is the same as or equivalent to the position in which the worker was employed before receiving the injury, or termination of weekly payments), or

• the entitlement to medical and like expenses first arising in a medical expenses only claim (date of first approved service),

the claim should undergo a medical and like entitlement review (MLER). During this review, Agents should determine whether:

• medical and like benefits should cease

• any exceptions apply that allow medical and like benefits to be maintained or varied.

Exceptions excluding a claim from the MLER

Medical and like benefits will not be affected by the 52 week rule where a worker:

• has received common law damages for pecuniary (economic) loss in respect of the same claim, even if those damages were paid by TAC Transport Accident Commission

• accepts a voluntary settlement A lump sum payment that replaces an injured worker's right to ongoing weekly compensation. of weekly payments under the legislation

• made a weekly payments claim before 12 November 1997 and has been assessed as having a ‘serious injury’ (30% whole person impairment).

See: 6.3 Common Law | 6.4 Settlements

Additional considerations for the MLER

Medical and like benefits may also continue beyond the 52 weeks if:

• a worker has returned to work but could not remain at work if the service was not provided

• a worker has returned to work but surgery is required

• a worker requires modification of a prosthesis

• the service is essential to ensuring a worker’s health or ability to complete necessary activities of daily living does not significantly deteriorate.

To determine if any of the above circumstances apply to a worker, a MLER may be required.

Note: The questions in the MLER process must be answered as at the date the Agent is completing the review, not the date the MLER process was initiated.

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