The treating doctor and workers' compensation under the SRC Act
The doctor plays an important role in helping the employee recover from work related injuries and diseases and (as far as possible) resuming their pre-injury lifestyle.
As part of this the doctor:
- provides a clear diagnosis to enable the medical aspects of a claim for compensation to be fully considered
- provides ongoing treatment for the employee’s work related injuries or diseases
- works with case managers and providers to assist the employee to return to work
For a claim to be accepted, a clear diagnosis of the condition is required together with an assessment of the employee’s fitness for duty. This is generally in accordance with the International Classification of Diseases, 9th Edition (ICD-9-CM). It is useful if the doctor can provide some guidance on any restrictions or modifications which would assist the employee return to work.
The doctor’s role
An injured employee is entitled to seek treatment from the medical practitioner of their choice. The treating doctor plays an important role in helping employees recover from occupational injuries and illnesses. As part of this role the treating doctor may:
- identify work related problems and support a claim for workers’ compensation benefits by completing the appropriate medical certification and/or reports. The employee will lodge their compensation claim with the medical certificate attached with their employer
- provide ongoing treatment for the employee’s work-related injuries or diseases
- provide regular medical certificates or reports (if required) on the employee’s progress
- facilitate the employee’s return to a productive work life by working with case managers and rehabilitation providers to identify suitable duties
- rate the degree of impairment when an employee’s condition has reached maximum improvement to assist an assessment of any permanent impairment payment to the employee which may be appropriate
- provide information to the Administrative Appeals Tribunal (AAT) where a dispute over the medical aspects of a claim may exist
Medical evidence needed for a claim to be accepted
An employee must include a medical certificate with their Claim for Rehabilitation and Compensation Form. Claims for workers’ compensation that are not supported by medical evidence cannot be accepted.
While Comcare has developed a medical certificate form to assist employees in lodging a claim, it is not mandatory to use this form. Treating doctors can use their own certificates but the acceptance of a claim for compensation may be delayed if all the necessary information is not available.
For a claim to be accepted the medical evidence provided must be from a legally qualified medical practitioner. Legally qualified medical practitioners include general practitioners, specialists or dentists. If a claim is only for medical expenses for chiropractic or osteopathic treatment, a medical certificate from a doctor is not required.
The medical evidence provided will assist in the determination of the employee’s claim. Where appropriate it may also assist in deciding whether a rehabilitation and return to work program should be initiated. Medical evidence should include:
- the date of the injury and the date the employee first sought treatment (however, the medical certificate must not be backdated)
- a clear diagnosis of the claimed condition
- an explanation of how the condition is related to the employment. The treating medical practitioner should advise whether in their opinion the condition is consistent with the explanation for the injury or disease provided by the employee
- an explanation of how the current injury or incident may have impacted on any pre-existing injuries or diseases or other contributory factors. Where a pre-existing condition does exist, an explanation of when the effects of the current injury or incident might cease
- any treatment (or restrictions) required for the condition and the likely duration of the condition and treatment (for example specialist referrals and rehabilitation)
- the period of time off work, if required, and expected date when the employee’s condition should be reviewed or a return to work will occur. (When a claims manager accepts liability for a claim, the period of liability will generally be consistent with the doctor’s certification. For example, if the doctor gives the employee a certificate stating that they need a month off work, then liability will be accepted for that month. For the claims manager to accept further liability, the employee will need to provide a further certificate.)
- an assessment of the employee’s fitness for duty including any restrictions or modifications to the employee’s normal duties. If the treating doctor considers that the employee is able to return to work but with some restrictions or modifications required, it is helpful if the treating doctor can provide a clear indication of what is required to achieve a return to work. Where necessary this will help to facilitate an assessment of the employee’s workplace.
The need for a clear diagnosis
Comcare has adopted the acceptance standard used in the interpretation of ‘injury’ in the ICD-9-CM. The National Centre for Classification in Health (NCCH) is responsible for the development of the ICD-9-CM. The NCCH website provides further information regarding this classification system.
If the employee’s condition is classified in accordance with the ICD-9-CM, or the ICD10, then it is accepted that the employee has an ‘injury’ as defined by the SRC Act. If not, and the certificate contains a diagnosis like ‘medical condition’, ‘back pain’ or ‘work related stress’ then a decision on liability may be delayed until the claims manager can clarify the employee’s condition with the treating doctor. Claims managers within Comcare have been advised to contact the treating doctor if the claimed condition is not classified within the ICD-9-CM. In most cases an alternative diagnosis can be provided and the claims manager can then determine the claim.
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