There are particular circumstances when compensation for medical and like services will no longer be paid. The circumstances could include the treatment or service is not reasonable or necessary due to service or treatment requested, the duration of time since the injury or since weekly payments ceased.
Time limit - provisional payments for a claimed mental injury
Where the worker is entitled to provisional payments for a claimed mental injury, compensation for medical and like services in relation to that injury will cease to be paid:
- If the claim is rejected - 13 weeks after the Agent has determined that a worker is entitled to provisional payments.
- If the claim is accepted, payments for reasonable medical and like services for the accepted injuries will continue in accordance with the workers’ compensation legislation – see heading below ‘Time limit – accepted claim for .compensation’
Time limit - accepted claims for compensation
Compensation for medical and like services will cease to be paid:
- 52 weeks after the entitlement to weekly payment ceases, unless exceptions apply
- 52 weeks after the occurrence of the compensable injury, if the claim was only for medical and like services, unless exceptions apply.
When medical and like services have been stopped, system records must be updated to prevent further medical and like payments to that worker.
Give the worker a minimum of 28 days' notice that payment for their medical and like service will be ceasing.
The notice must inform the worker of their appeal rights.
If the Agent is aware of service providers who have been providing regular services to the worker, inform the provider/s of the intention to cease medical and like benefits for the worker.
Note: Informing the service provider/s will reduce the risk The probability of the worker not returning to work is known as the risk or risk factor. For example: if a worker is likely to return to work, the claim is categorised as low risk. of disputes about ongoing responsibility for paying medical and like costs.
Worker has received settlement or common law entitlement
The 52 week entitlement review does not apply if a worker has received either of the following:
- a voluntary settlement A lump sum payment that replaces an injured worker's right to ongoing weekly compensation. under the legislation
- their entitlement to common law under either the legislation or the TAC Act Transport Accident Act 1986 with a pecuniary loss A loss of earning capacity component.
In these circumstances the worker’s continuing entitlement to medical and like services is still subject to the legislation.
Compensation for medical and like services may continue beyond the time limits specified in the legislation if:
- the worker has returned to work but:
- could not remain at work if the service is not provided
- surgery is required
- the worker still has a serious injury within the meaning of the legislation
- the worker requires modification of a prosthesis
- the service provided is essential to ensuring that the worker’s health or ability to undertake the necessary activities of daily living does not significantly deteriorate.
Plan for ongoing medical & like services
Where it is determined that a worker should continue to receive compensation for medical and like services, the Agent should:
- initiate the development of a treatment plan for ongoing medical and like services
- negotiate agreement about this plan with the worker and the treating practitioner.