Does WorkCover pay for surgery?

Does WorkCover pay for surgery

Yes, generally speaking, WorkCover will pay for surgery, provided that surgery relates to your work related injury.

Before you have the surgery, you will need to obtain written approval from the WorkCover insurer.

They may wish to have you medically assessed after you send a request for surgery to them. They may also seek further information from the surgeon.

In some cases, a WorkCover insurer will reject a surgery request. This might happen, for example, if they believe that the surgery is not clinically justified. In cases such as this, you are able to appeal the decision.

How do I request that the insurer pay for the cost of surgery?

Your surgeon should send a request for surgery to the WorkCover insurer.

The request for surgery needs to be in writing and include the following;

  • Your name and claim number
  • A description of the surgery requested
  • Address the¬†relationship between the surgery and the work related injury
  • The MBS item number that relates to the surgery

What happens once a request has been submitted?

The insurer will take some time to make a decision on the surgery request.

Within 10 working days of receiving the request for surgery, the WorkCover insurer should let you know whether they accept or reject the surgery request.

If they require further information in order to make a decision, then they should let you know that they require further information within 10 working days of receiving the surgery request.

In relation to what further information may be requested, they may require further information from your treating surgeon about why the surgery is required and how it is clinically justified.

In some cases, they may organise for you to be assessed by an independent medical examiner so they can obtain a second opinion.

The WorkCover insurer should let you know whether the surgery request has been accepted or rejected within 10 working days of receiving the additional information that they requested.

What happens if the surgery request is accepted?

You can then proceed to having the surgery. You should make contact with your surgeon to ensure that they are aware and so an appointment can be scheduled.

Because you are not on the public list, the surgery should happen without too much delay.

What fees will the WorkCover insurer pay for surgery?

They will pay the cost of surgery, but they will pay in accordance with a set fee schedule.

For this reason, it is a good idea, prior to any surgery, to speak to your surgeon and insure that the total cost of the surgery will be paid for by the WorkCover insurer and that there is no gap that will need to be covered by you.

The WorkCover insurer will pay for any post surgical rehabilitation costs in accordance with the act.

If you wish to review the face schedules waiting to surgery and associated costs, then you can visit the WorkSafe website.

What happens if the surgery request is rejected?

What happens if workcover reject surgery request

You have appeal rights if this occurs.

You should visit this page which will explain how to contest a decision from the insurance company.

In a nutshell, the first step is to contact the insurance company and find out why the surgery request was rejected. It may be that they simply require further information which you can chase up and provide to them.

The second step, if the insurer maintains their decision, is to issue the matter to conciliation. 

If the matter does not resolve at conciliation, then you can proceed to either the medical panel or to court.

You are able to go on the public waiting list in the meantime while you wait for the decision to reject your surgery to be dealt with.

If you manage to have the surgery under the public system, if there are any outstanding costs, these can be paid for by the insurance company if they except the surgery request.

Conclusion

WorkCover will pay for the cost of surgery, provided there is medical material to support the fact that you need it, and that it is for the treatment of your work related injury.

Before having surgery you will need to get written approval from the WorkCover insurer. Your surgeon should send a request for surgery to them.

After this request gets received, they have ten days to make a decision. They may require further information in order to make a decision, however. Once they receive this information, they should inform you of their decision within ten days.

If your request for surgery is rejected, then you are able to appeal.

Please keep in mind that the information contained on this page should not be considered legal advice and no content on this site should replace the need to obtain advice tailored to the specific facts of your case. The facts of a case can significantly alter the advice that can provided. This site only provides general advice. Read more here.

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To contact Michael or Peter call 1800 746 442 or email [email protected]

Written by the Work Injury Site team