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22.1.1 Underlying principles

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The underlying principles for the approval of medical treatment as being reasonable to obtain  are that treatment:

  • be necessary to improve any conditions for which the client has accepted liability
  • do no harm
  • be of a reasonable cost (considering the cost of treatment against the expected gains)
  • be clinically effective (considering the available evidence)
  • be accepted clinical practice (considering the current professional opinion).

 

The treating practitioner is in the best position to decide the treatment in line with the principles above. It may be necessary to seek additional medical opinion e.g. from a psychiatrist or pain specialist. Departmental Medical Officers (DMO) can also provide opinion but this needs to be weighed in conjunction with other evidence. It is relevant to note that the DMO is not normally a specialist and in most cases will conduct file reviews only. It is still the responsibility of the delegate to make a decision on reasonableness, taking into account the particular circumstances of the case. This delegation should not be abrogated to a DMO or other health professional.

 

Whilst all operations and most medications have risks and side effects they should not be ruled out on the basis of 'doing no harm'. This issue always needs to be weighed in conjunction with 'Being clinically effective'. It is reasonable to expect that the treating practitioner has discussed this issue with the claimant and as such both consider it a reasonable course of action. If there is doubt about this clarification should be sought from the claimant and the treating practitioner.

 

When considering costs the delegate should also take into account the potential for a reduction in future liability if the treatment is successful, e.g. reduced PI or medical costs or enhanced capacity for work. Whilst providers are not bound to adhere to any particular schedule of fees, where such exist, if the fee demanded by the provider is excessive when compared to the schedule, it is incumbent upon to the delegate to ask further questions of the provider to establish the reasonableness of the cost.

 

Accepted clinical practice can include new or experimental procedures however these are often costly and the effectiveness is not always known. As such delegates should exercise considerable caution before approving such treatment. In such a situation alternative options should be considered along side the proposed treatment.

 

In this context, the question of reasonableness is first and foremost a medical and financial consideration, rather than a legal one.