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Section 16 (1), like many other sections of the Act, indicates that decisions must be made based on the 'reasonableness' of compensation claims.

The section requires consideration of how reasonable the type of treatment is in relation to the employee's condition, not forgetting “in the circumstances”.

“In the circumstances” allows some leeway when taking into account the merits of the particular case.

An employee is on a waiting list to visit an ACT Orthopaedic Surgeon, but cannot see the specialist for another three months.

Because her condition is not getting any better, she arranges an appointment with a Sydney specialist who can see her almost immediately.

In this circumstance, it is probably reasonable that the employee travel to Sydney to obtain treatment rather than wait for an appointment with the ACT specialist.

Also consider:

  • what other treatment the employee is receiving;

  • medical evidence on the claim;

  • the dollar cost, frequency, duration and outcomes of the course of treatment; and

  • what treatment is necessary vs what is desired (that is, what the employee wants rather than needs).

An important aspect to consider is that of secondary conditions which may result from the compensable injury.

Examples

Severe back injury resulting in depression

Ankle fracture resulting in back strain

Knee injury resulting in hip displacement

Side affects from the use of a specific drug taken to assist with the compensable condition

Where one condition clearly emanates from the other, compensation should be paid for both conditions.  In particular, pharmaceuticals prescribed for secondary conditions may occasionally be submitted for consideration, even though the treating doctor has not indicated that such a condition relates to the original injury.

There are three things which can be done to assist in deciding whether a secondary condition has arisen from a compensable injury:

  • use of commonsense.  Quite often, it is clearly reasonable that one condition results in another;

  • checking MIMs, which provides information on side effects and links between many illnesses; and

  • further medical evidence from the treating doctor.