Medical expenses
33 Medical expenses
Subject to this section, a worker is entitled to be compensated for costs of services described in subsection (2) that are reasonably incurred by the worker in consequence of having suffered a work injury—
in accordance with a scale published by the Minister under this section; or
if the relevant service is not covered by a scale under this section—to the extent of a reasonable amount for the provision of the service.
The costs referred to in subsection (1) are the necessary costs of:
medical services;
hospitalisation and all associated medical, surgical and nursing services;
approved recovery/return to work services;
travelling, or being transported, to and from any place for the purpose of receiving medical services, hospitalisation or approved recovery/return to work services (but not where the worker travels in a private vehicle);
where it is necessary for the worker to be accommodated away from home for the purpose of receiving medical services or approved recovery/return to work services—such accommodation (but not exceeding limits prescribed by regulation);
attendance by a registered or enrolled nurse, or by some other person approved by the Corporation or of a class approved by the Corporation, where the injury is such that the worker must have nursing or personal attendance;
the provision, maintenance, replacement or repair of therapeutic appliances;
medicines and other material purchased on the prescription or recommendation of a health practitioner;
other services (or classes of services) authorised by the
Corporation.
Compensation in respect of costs to which this section applies may be paid—
to the worker; or
directly to the person to whom the worker is liable for those costs.
If a worker has been charged more than the amount that the worker is entitled to claim for the provision of a service in respect of which compensation is payable under this section, the Corporation may reduce the charge by the amount of the excess.
A decision of the Corporation under subsection (4) does not constitute a reviewable decision under Part 6.
If—
services of a kind to which this section applies were provided to a worker in relation to a work injury; and
the Corporation considers that the services were, in the circumstances of the case, unnecessary or unreasonably incurred, the Corporation may disallow charges for the services.
If the Corporation disallows or reduces a charge under this section—
it must give to the provider of the service a notice setting out—
the basis of the Corporation's decision to disallow or reduce the charge; and
where the charge has been disallowed under subsection (6) the provider's right to have the decision reviewed under this section; and
the worker is not liable to the provider for the disallowed charge, or for more than the reduced charge, (as the case requires) and, if the worker has in fact paid an amount for which he or she is not liable, the Corporation will reimburse the worker for that amount and may recover it from the provider as a debt.
If a worker travels in a private vehicle to or from any place for the purpose of receiving medical services, hospitalisation or approved recovery/return to work services, and the travel is reasonably necessary in the circumstances of the case, the worker is entitled to a travel allowance at rates fixed by a scale published by the Minister under this section.
A reference in this section to approved recovery/return to work services is a reference to recovery/return to work services provided by a person who has an agreement with the Corporation for the provision of those services.
If a treatment protocol or framework for the provision of services has been published by the Minister under this section, costs for the provision of those services are only compensable where—
the services are provided in accordance with the protocol or framework; or
the provider of the services establishes, to the Corporation's satisfaction, that services outside the terms of the protocol or framework are justified in the circumstances of the particular case.
The amount of compensation for a service covered by a scale of charges published by the Minister under this section must be in accordance with the scale.
The Minister may, by notice in the Gazette, on the recommendation of the Corporation, publish—
scales of charges for the purposes of this section (ensuring as far as practicable that the scales comprehensively cover the various kinds of services to which this section applies);
treatment protocols or frameworks as contemplated by this section.
Subject to subsection (14), a scale of charges published under this section must be based on the average charge to private patients for the relevant service unless the Minister determines that it is not reasonably practicable or feasible to determine such an average charge for a relevant service (but in any event the amount fixed for the service must not exceed the amount recommended by the relevant professional association).
A scale of charges for services provided by a public hospital may be based on government charges for the relevant service.
Before the Corporation makes a recommendation to the Minister about the publishing of a scale of charges, or a treatment protocol or framework, the
Corporation must consult with—
professional associations representing the providers of medical services of the relevant kind; and
associations representing self‑insured employers (including
Self-Insurers of South Australia Incorporated); and
associations representing employers other than self‑insured employers (including the South Australian Employers Chamber of Commerce and
Industry); and
associations representing employees (including the United Trades and Labor Council).
A person who provides a service for an injured worker, knowing the worker to be entitled to compensation for the service under this section, must not charge for the service an amount exceeding the amount allowed under a scale of charges published under this section. Maximum penalty: $2 500.
A worker is entitled, in relation to prescribed classes of services, appliances, medicines or materials referred to in subsection (2), to apply to the Corporation for approval to obtain the provision of those services or otherwise to incur costs on the basis that the Corporation will agree in advance to be liable for the relevant costs rather than the worker being required to claim compensation under this section once the costs have been incurred.
An application under subsection (17) must be made in accordance with the regulations and the Corporation must make a decision in relation to the application within the period prescribed by the regulations.
The Corporation must give the same consideration to an application under subsection (17) that would be given to an application if the worker were to incur the relevant costs and then claim compensation under subsection (1).
Subject to subsection (21), an entitlement to compensation under this section (including an entitlement to make an application under subsection (17)) comes to an end if the worker has not had an entitlement to receive weekly payments in relation to the work injury under Division 4 for a continuous period of 12 months (or has not had an entitlement to receive weekly payments under Division 4 and a period of
12 months has expired) (insofar as costs are incurred after the end of that period).
Subsection (20)—
does not apply in relation to a seriously injured worker; and
does not apply—
in relation to any therapeutic appliance required to maintain the worker's capacity; or
in relation to surgery, any associated medical, nursing or medical rehabilitation services (including the cost of hospitalisation), where the
Corporation has determined or accepted, on application made before the end of the period referred to in subsection (20), that it is reasonable and appropriate for such surgery to be undertaken at a later time due to the impact (or likely impact) of the work injury on the worker's health and capacity (or future health and capacity); or
in relation to prescribed classes of injury, where the Corporation has determined or accepted, on application made before the end of the period referred to in subsection (20), that it is reasonable and appropriate for the services to be provided after the end of that period (and then, in such a case, the services will be compensable to the extent determined by the Corporation); or
in any other circumstances prescribed by the regulations.
The right of review referred to in subsection (7)(a)(ii) is a right to have the decision of the Corporation to disallow or reduce a charge reviewed by the Tribunal by application to the Tribunal under the South Australian Employment Tribunal
Act 2014.
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