One of the disputes workers compensation clients will encounter with insurance companies is whether treatment is reasonably necessary following a workplace injury. The relevant section of the Workers Compensation Act 1987 NSW is section 60. If the dispute is before an Arbitrator in the Workers Compensation Commission they will need to consider the following before deciding on whether treatment is reasonably necessary or not, as noted in Rose v Health Commission (NSW) (1986) 2 NSWCCR 32:
a) The appropriateness of the particular treatment;
b) The availability of alternative treatment, and its potential effectiveness;
c) The cost of the treatment;
d) The actual or potential effectiveness of the treatment; and
e) The acceptance by medical experts of the treatment as being appropriate and likely to be effective.
In the matter of Laing v Sydney Catholic Schools Limited [2020] NSWWCC 19 the timeliness of surgery was considered. The worker had injured her left knee at work on 23 March 2016 and had been advised that a total knee replacement would be required. However no surgeon had requested approval to perform the surgery from the insurer and no medical expert advised that the surgery was required now. It was anticipated surgery would be required at some point but there was no evidence to state that surgery was required right at this point. The Arbitrator could not rule in favour of the worker based on the evidence before her therefore the insurer was successful in disputing the claim.
If you have been injured and the insurer has denied your claim for surgery please contact our office for advice because Helping You is Our Business.
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