Stuck in the waiting room? How long the Insurer can take to make a decision

Stuck in the waiting room? How long the Insurer can take to make a decision

It can be concerning and frustrating when you are waiting for your Workers’ Compensation Insurer to make a decision regarding your medical treatment.  You may feel like you’re stuck – you know you need the treatment to assist your recovery, but you cannot obtain it until you receive approval – or can you? 

Medical treatment that does not require pre-approval 

If your Insurer has accepted your claim, you can access some forms of medical treatment and services without obtaining pre-approval from your Insurer.  These include: 

  • ambulance services;
  • initial treatment provided within the first 48 hours of your injury;
  • services provided in an emergency department of a public hospital relating to your injury;
  • consultations with a nominated treating doctor (usually your GP);
  • some diagnostic investigations within a certain period from the date of your injury (for example, x-rays within two weeks and other investigations such as ultrasounds and MRIs within three months);
  • some pharmaceutical items prescribed by your nominated treating doctor or medical specialist;
  • up to eight consultations for physiotherapy, osteopathy or chiropractic treatment (only one type of treatment will be funded at a time by your insurer), or up to eight sessions of psychological treatment or counselling, if the treatment commences within three months of your injury.

Medical treatment that does require pre-approval

Other treatments, however, do require pre-approval from your Insurer.  Common examples include ongoing physiotherapy, injections, surgery and inpatient psychiatric treatment.  

Your GP, Specialist or treatment provider should send a written request for approval of the proposed treatment to your Insurer.  We suggest you follow up this email with a phone call to your Claims Officer.  Your Insurer must then make a decision regarding the treatment proposed within 21 days of receiving the request.  In making its decision, your Insurer will be assessing whether the proposed treatment relates to your work injury and is reasonably necessary. 

What if I just pay for the treatment myself, and then seek reimbursement?

In some situations, you may choose to pay for your treatment upfront and then seek reimbursement from your Insurer later. 

This can be the easiest option for smaller expenses, for example, travel to a Specialist appointment.  You may not know beforehand how much your train or taxi fares will cost so it is easier to hold onto your receipts and seek reimbursement afterwards. 

Whilst we do not recommend this for significant expenses (as there is no guarantee you will receive reimbursement), we understand it is sometimes necessary if the treatment is urgent and you cannot wait for your Insurer to make a decision within the 21-day timeframe.

A request for reimbursement of medical expenses should be submitted to your Insurer within six months of your treatment. Your Insurer then has 30 days to reimburse you.

But what if my Insurer declines to pay for my treatment or reimbursement?

Whether you have sought pre-approval from your Insurer or not, your Insurer may decline to pay for, or reimburse you for, your medical expenses.  If your Insurer does so, it should provide you with written correspondence, called a Section 78 Notice, that sets out the treatment it is declining and its reasons for doing so.

If this happens, you should get in touch with your Solicitor immediately. 

We may seek additional evidence from your treating medical practitioners, or an Independent Doctor, regarding why the treatment is related and reasonably necessary.  Your Insurer has 14 days to review its decision and may withdraw its decision at that time.  We are confident in asking your Insurer to review its decisions.  We do this all the time.  Upon a recent request for review, an Insurer withdrew its decision to decline payment for injections into our client’s cervical spine. 

If your Insurer maintains its decision to decline your treatment, we can immediately commence proceedings in the Personal Injury Commission (“PIC”) on your behalf, where a Member of the PIC will review the evidence and make a binding decision regarding whether your Insurer should pay for your treatment.  At a recent PIC teleconference, an Insurer withdrew its decision to deny liability for a secondary injury to a different shoulder and agreed to pay for surgery to that shoulder.  At a recent teleconference for a different client, an Insurer withdrew its decision to refuse to pay for a trial of a spinal stimulator.

We can help you

We understand how important it is that you receive appropriate and timely medical treatment.  Please contact Bourke Legal if you have any enquiries regarding approval of your treatment or Insurer approval timeframes, or if your Insurer has declined to pay for any treatment you require.  We can help you navigate this process.