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Section 60 of the Workers Compensation Act 1987 (NSW) states that:
the worker’s employer is liable to pay, in addition to any other compensation under this Act, the cost of that treatment or service and the related travel expenses specified in subsection (2).
Therefore, the key question is whether the proposed treatment is ‘reasonably necessary’.
So, what is ‘reasonably necessary’? To the layman, this sounds like such a broad concept. However, this question was answered in the case of Diab v NRMA Ltd  NSWWCCPD 72, whereby the then Workers Compensation Commission held the view that the following matters are to be considered when determining whether a proposed treatment is ‘reasonably necessary’:
the appropriateness of the particular treatment;
the availability of alternative treatment, and its potential effectiveness;
the cost of the treatment;
the actual or potential effectiveness of the treatment, and
the acceptance by medical experts of the treatment as being appropriate and likely to be effective.
Therefore, having your doctor simply make a referral for a proposed treatment (in particular to treatment such as surgery) without addressing the above factors, will most likely be insufficient for the insurer to approve the proposed treatment. The insurer will consider the medical evidence on file and may ask your treating doctors for more information before making a decision.
If the insurer disputes liability for the proposed treatment, they are required to provide this decision in writing, commonly known as a “Section 78 Notice”. The insurer may dispute liability for the injury and subsequent related treatment or accept liability for the injury but dispute liability for the proposed treatment on the basis that it is not ‘reasonably necessary’. Regardless of what the insurer disputes, they must provide their reasoning and include any evidence they have relied upon to make their decision.
If you have received a Section 78 Notice, or if the insurer has informed you that they will not be paying for your proposed treatment, you should contact Littles Lawyers immediately for legal advice.
Further, in most cases, the insurer only has 21 days from the date they received the treatment request to make a decision. If the insurer has exceeded this timeframe of 21 days, you should contact Littles Lawyers so we can represent you and assist you with getting your treatment approved.
Our Head of NSW Claims, Jessica Cheung is an approved lawyer with the Independent Legal Assistance and Review Service (ILARS) scheme and therefore we can apply for ILARS grant funding on your behalf. If IRO approves your ILARS grant application, IRO will pay for your legal fees and any disbursements. Therefore, you can access and retain our legal services to provide you with comprehensive legal advice and/or assist you to challenge and overturn the insurer’s Section 78 Notice with no cost payable by you.
纤维肌痛(Fibromyalgia)是什么? 纤维肌痛症是一种弥漫性肌肉骨骼疼痛的疾病。其伴随症状包括疲劳以及记忆、睡眠和情绪问题。 纤维肌痛并没有明显以及固定的诱发因素。有些病患是因为单一事件后开始出现症状，有些则是随时间推移慢慢出现相关症状并愈发严重。 目前的医学发展无法根治纤维肌痛症，现有的治疗主要是通过药物控制症状。 纤维肌痛患者可以申请TPD保险赔偿吗 ？了解您的权利 首先，大部分的残疾保险并不由病因决定索赔的成败。这表示导致您无法工作的疾病或者受伤的因素并不起决定性的作用。 如果您被确诊患上纤维肌痛，引起伤残问题导致无法回到您原来受的教育、训练以及经验相关的工作，那您有可能可以针对您的完全和永久性伤残保险(Total and Permanent Disability Insurance, 以下简称TPD保险)进行索赔。 由于纤维肌痛的确诊以及症状比较存在争议，为了保障您的权益，获得法律建议以及熟悉相关疾病的医生至关重要。 以上的信息也同样适用于患有复杂性局部疼痛综合征(简称CRPS)以及慢性疲劳综合征(简称CFS)的患者。 退休金以及各类保险的分别 很多人不清楚自己的退休金(superannuation)到底包含了什么投资以及保险。每一个退休金机构(super fund) 对于选购保险的运作方式不同，所提供的保险种类、计划以及福利也不尽相同。所以，您需要了解到底您的退休金机构自带的保险 (default...Read More