Hypothetical – Insurer Declines Injured Worker’s Surgery Claim


SANDRA was employed as a nurse when she unfortunately suffered a serious back injury.

She was trying to assist a patient into a wheelchair when she heard a snap in her back and felt an immediate shooting pain in her right leg.

As a result of her injury, Sandra was unable to return to work.

Under the workers compensation scheme, Sandra is entitled to a number of benefits, including weekly wage payments, treatment expenses and a lump sum payout.

The workers compensation insurer accepted liability for the claim and commenced her weekly wage payments.

Over the course of five months, Sandra underwent extensive physiotherapy and was on daily pain medication, with little relief in her symptoms.

Sandra then attended a consultation with a spinal surgeon, who was of the opinion that Sandra needed spinal surgery.

However, the insurer declined to pay for the surgery, stating it was not “reasonable and necessary”.

The insurer found evidence of a pre-existing back condition in Sandra’s medical history and also decided that the surgery would have been inevitable in any event, regardless of the workplace accident taking place.

Distressed by the decision, Sandra contacted a lawyer who helped her lodge a dispute in the Workers Compensation Commission to challenge the insurer’s decision.

The Commission ultimately held that although Sandra suffered from a pre-existing back condition, her workplace incident aggravated it to the extent that it was the main contributing factor to her current symptoms.

The Commission therefore deemed the proposed surgery to be reasonable and necessary.

The insurer was ordered to overturn their previous decision and Sandra was able to proceed with the surgery and begin her road to recovery.

Thank you to our personal injury expert, Antonela Josipovic, for her assistance with this column.

Call (02) 6648 7487 or visit ticliblaxland.com.au.

By Manny WOOD

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