Gym swim programs and WorkCover

If you have suffered an injury related to your employment and you have lodged and had accepted a WorkCover claim, the WorkCover insurer may pay for a gym/swim program for you.

In order to have the insurer pay for a gym or swim program, or both, you will need medical material in support.

This page will explore this topic further.

What exactly is a gym swim program?

The WorkCover insurer will consider paying for a gym or swim program to assist you with rehabilitation.

It is considered a medical and like expense.

It is for you to perform exercise programs in a gym and or pool independently, to assist you in your recovery of your work related injury.

Gym and swim programs are usually developed and monitored by your healthcare provider.

These healthcare providers are usually medical practitioners, physiotherapists, chiropractors and osteopaths.

How do I go about getting the insurer to pay for a gym swim program?

The first thing that you will need to do is to speak to your health care provider about it.

If you’re not seeing a healthcare provider currently and you believe that a gym or swim program my assist, you should make an appointment to see someone for treatment.

You’ll need to obtain a written request from your healthcare provider.

The insurer will accept written requests from a registered medical practitioner, a physiotherapist, a chiropractor or an osteopath.

If the written request comes from a healthcare provider of yours that is not one of these, the insurer is likely to reject your request.

The written request should detail:

• The nature of what is requested (gym or swim membership or both)
• The reason this is required and
• The period for which it is required.

In relation to the period, the insurer usually will only consider paying for periods of up to 3 months at a time.

So say for example if the insurer approves your request and pays for a three month gym swim program, if you wish to continue this program you’ll need to submit another request to the insurer for another period.

In relation to medical support, you will of course need the support from the medical practitioner, physiotherapist, chiropractor or osteopath who is recommending that you undergo the gym or swim program.

However, if you have other medical material from someone else that has been treating you such as then you could submit this to the insurer as well (if you have a lawyer, you should ask them whether it’s ok to submit this extra material before you do so – particularly the case if you intend to pursue a common law claim at some point).

In terms of submitting the request to the insurer, you should send it directly to your claims manager and ask them to confirm receipt.

They should generally only need a couple of weeks to consider the request unless there is further material that they need.

In relation to further material they may for example need clarification from your medical practitioner, physiotherapist chiropractor or osteopath in relation to a specific part of the request.

If you haven’t heard from the insurer within a couple of weeks from when the request was sent to them it might be a good idea to call them and follow up with them just to make sure that things are progressing.

If they approve the request

The Insurer should send you confirmation in writing that they have approved your request for a gym swim membership.

This approval letter should detail exactly what has been approved and for how long.

You should then contact the provider (the gym or swim complex) and confirm with them that the insurance company have approved your request.

If they need written confirmation you are able to send them a copy of your approval letter from the insurer.

You should ask them to bill the insurer directly ensuring to quote your claim number. You should ask them to let them know if there are any issues with receiving payment from the insurance company.

You should also contact your medical practitioner, physiotherapist chiropractor or osteopath and let them know the gym swim program has been approved.

The insurer will usually let the provider know but it is always a good idea for you to contact them.

It is important to keep in mind that the WorkCover insurer will approve gym swim programs for no more than three months at a time, generally.

If you are approaching the three month period and your healthcare provider suggests that you should continue with the gym swim program, then you’ll need to submit a new request to the insurance company that they fund another period.

We recommend that you do this as soon as possible because the insurer can take some time to process these requests.

If they reject the request

If the insurer rejects the request then you can ask them to perform an internal review.

You can also lodge a request for conciliation.

If the matter fails to resolve at conciliation, then you do have further appeal rights.

If you appeal the decision to reject the request, you have to be mindful of the fact that it can take some time for these few avenues to run their course.

It might therefore be reasonable if you really need the gym swim program for you to pay for the  program/s yourself and then if your request is approved down the track you can potentially be paid back all or the majority of what you’ve paid.

How many gym swim programs will the insurer pay for?

There is no cap on how many programs the WorkCover insurer will pay for but there is a limit in terms of how long they will pay for.

The WorkCover insurer will usually stop paying for gym and swim programs when your functional condition has stabilised.

So if while you are undergoing the gym swim rehabilitation programs and you are showing clinical improvement, then if you have support from a healthcare provider in relation of this the insurer should continue paying for gym swim programs.

If however your recovery has plateaued and the gym swim programs are not improving your condition, then the insurer may refuse to pay for any further gym swim programs.

How much will the insurer pay for gym swim programs?

You should contact the insurer and ask them how much they will pay in your particular instance.

The insurer has set fees they will pay for gym swim programs so in some instances you may be required to pay the gap amount between what the insurer is willing to pay and what the fees of the provider are.

Some providers, if they’re aware that a WorkCover insurance company is paying the fees, will reduce their fees to the amount that the WorkCover insurer will pay so you don’t have to pay anything further.

Conclusion

If you’ve got an accepted WorkCover claim the WorkCover insurer may pay for the reasonable costs of a gym and or swim exercise program for you.

You will need to have a written request from your healthcare provider (such as a medical practitioner, physiotherapist, chiropractor or osteopath).

The insurer will need to consider the request and if approved they will usually only approve for no more than three months at a time. If you need more than three months you will need to submit another request to the insurer. If the insurer reject the request you’re able to appeal this decision.