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Ch 1 Overview
Under S16 of the Safety, Rehabilitation and Compensation Act 1988 (SRCA), the Military Rehabilitation and Compensation Commission (MRCC) is liable to pay for medical expenses reasonably required for the medical condition associated with accepted claims for compensation.
From late - September 2012, a Treatment Authority letter will be issued to clients setting out a specified authority for treatment of the accepted conditions. Treatment Expectations will be available for providers which set out DVA's expectations for an appropriate level of service. These pre-treatment guides will remove the need for clients and providers to seek prior approval for the majority of primary care and allied health services.
In most cases payment of medical expenses is relatively straightforward. Problems usually exist where claimants seek reimbursement for medications not seemingly related to the accepted condition(s). These claims will require liaison with both claimant and medical provider to establish bona fides of any such request. There may be times when this investigation could lead to a claim for a sequela condition. Reference to the Liability Handbook will assist delegates in these situations.
The cost of medications or other services will from time to time cause delegates to have concerns. When deciding what amount is appropriate to pay for a particular medical treatment regard should be given to what is generally charged by similar service providers. If the cost that DVA is asked to pay is within a reasonable mean of such services then delegates should approve the service. The AAT case of Sinclair and Comcare (2002) is a useful reference point. This can often be an issue when considering costs of gym memberships etc. Provided these costs are within a range applicable to that service payment should be approved, provided that the criteria included in this handbook is addressed.
Advice on the suitability and cost of medications for claimants can also be obtained through the Veterans' Affairs Pharmaceutical Advisory Centre (VAPAC). VAPAC's role is to advise all elements of DVA on the provision of pharmaceuticals, and they can even liaise with providers and clients on the range, suitability and cost of medications.
There will also be occasions where suggested medical treatment (mainly but not exclusively operative procedures) could be seen as lacking empirical stature. This could include surgery using still relatively new devices or hardware. There may also be operations of 'last resort' leading to irreversible procedures in relatively young people. While these may give a reasonable outcome delegates considering requests should proceed with full awareness of what the outcome of the procedure will do in relation to the claimants condition. Delegates should not hesitate in seeking a second opinion as to the reasonableness of the treatment proposed. Use of Departmental medical advisers will assist in these situations.
Whilst some of the writings in this handbook are prescriptive the intent is to ensure the service requested is appropriate to the needs of the claimant and directed toward a beneficial outcome.