You are here

Comparison of third party insurers

Document

Comparison of third party insurers' reasonableness for gymnasium-pool memberships

This information was used to inform the current DVA policy guidelines on gymnasium-pool memberships.

Third Party Insurer

Key Points

Comparison of third party insurers' reasonableness for gymnasium-pool memberships

WorkSafe Victoria 
(Fee Schedule and Information for gym and swim providers)

  • Max rate 3 months $398.75
  • Pay reasonable costs of a gym/swim program to assist a worker in the rehabilitation of a work related injury or illness and to transition to independence or a self managed exercise program
  • Premises should provide evidence of current public liability insurance for a gym and/or pool of at least $5 million
  • Definition: gym and swim programs are structured exercise programs that are developed and monitored by a healthcare professional for a worker to perform independently in a gym and/or pool for the purpose of rehabilitation. Programs are for a fixed duration generally 3 months.
  • Will pay when :
  • It will assist the worker achieve specific work-related and functional goals and transition to independence or a self managed program
  • Written plan includes specific work related and functional goals and at least one current baseline standardised functional outcome measure
  • The plan includes details  of set up, monitoring and evaluating the program
  • The program is identified as reasonable and necessary.
  • Will consider an extension when the written plan includes an evaluation of the previous program and reason why the worker requires an additional program, also includes baseline and serial outcome measures
  • Will consider payment for a program longer than 3 months in exceptional circumstances – where worker has a complex injury such as spinal cord injury, acquired brain injury, crush injury, multiple orthopaedic injuries, amputations.
  • Will not pay
  • if there is not a written plan, that are not related to rehabilitation,
  • if the program has a primary focus on general fitness
  • for personal trainers
  • for swimming lessons
  • clothing
  • more than one program at one time

Motor Accidents Authority NSW

  • pay for services which are considered reasonable and necessary
  • consider the following when making a decision
    • relationship of the service to the accident
    • benefit to the claimant –how will the outcome of the service progress/maintain the claimants recovery/management; what would be the outcome of not providing the service; is there sufficient documentation to support that the requested service will be of benefit to the claimant
    • appropriateness of the service – is the service consistent with the current medical or rehabilitation management; is there a similar service currently provided; what related services
    • appropriateness of the provider
    • cost considerations
  • reasonable and necessary criteria
    • is there sufficient evidence that the services relate to the injuries sustained
    • what benefit to the client will be gained by the service
    • what will be the outcome of not providing the service
    • is there sufficient documentation that the requested service will be of benefit to the claimant
  • is the proposed service appropriate for the injuries?
    • is there a similar service currently provided
    • what related services have been provided in the past and what was the outcome
    • is the service in keeping with current best practise/clinical guidelines
    • is there good evidence the service is not effective
    • are there any contradictions for the service
    • what are the goals and expected outcomes

TAC Victoria

TAC can fund the reasonable cost of an independent fixed term gym or swim program for the purpose of rehabilitation.

TAC recognise that a client may benefit from a fixed term gymnasium or swimming program where it:

  • Is clinically justified and will assist client achieve physical rehabilitation goals
  • Is monitored by the provider
  • Will assist client to transition from provider based treatment to a self managed program

Once the clients condition stabilises the programs becomes maintenance and client is responsible for future programs. The client will be reimbursed only after it is confirmed the client attends regularly.

Need

  • Evidence of functional goals
  • Current clinical status and baseline outcome measures
  • Outcome measures throughout the program
  • Confirmation the client understands how to safely perform the exercises
  • Evidence the program will be monitored on a regular basis

Extension of programs will only be considered in exceptional circumstances where:

  • The request includes the current rehabilitation goals and time lines
  • Method and frequency of evaluation

TAC will not fund:

  • Extra facilities eg spa. Sauna
  • Personal trainers
  • A gym that offers extra services and the client chooses this in preference to a standard gym
  • A maintenance program
  • Gym clothing
  • Gym programs that are not clinically justified
  • Treatment, services or equipment that is not evidence based or is not safe

Request form – asks – Do your outcome measures suggest the client is in – maintenance , rehabilitation or unsure

Comcare

SRCA 1988

Request form includes questions such as:

  • Have you previously attended a gym – facility details, when ?
  • How is the gym program related to the accepted condition?
  • Supply a detailed program outline
  • Can the employee perform the required exercises at home – if not why not?
  • If the employee is currently out of work how will this program facilitate a return to work?