Medical evidence

Why medical evidence is required

When making a claim for workers' compensation, you must submit medical evidence.

Medical evidence is required:

• to make a determination on your claim
• for your claims manager to consider medical treatment and other support
• to help manage your claim and determine your capacity for rehabilitation.

Medical evidence is usually in the form of a certificate of capacity, medical certificate or medical report.

Medical certificates

A certificate of capacity or a medical certificate must be provided when you make a claim under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act).

Who can provide a certificate

You usually need a certificate of capacity or medical certificate from a legally qualified medical practitioner (LQMP).

Under the Safety, Rehabilitation and Compensation Act 1988, a LQMP can be a General Practitioner or a specialist, such as a Surgeon, Psychiatrist or a Dentist.

A certificate of capacity or medical certificate must be provided by a LQMP if you want to claim for income support. The certificate needs to state how the injury or illness is related to your work.

You do not need to provide a certificate of capacity or medical certificate from a LQMP if you are only claiming for treatment provided by:

• an Occupational Therapist
• an Osteopath
• a Chiropractor
• a Dentist
• a Psychologist
• an Optometrist, or
• a Physiotherapist or Massage Therapist.

In these cases, you can provide a certificate of capacity or medical certificate from the allied health provider stating a precise diagnosis and cause for the injury or illness.

Form of the certificate

Comcare's preferred medical certificate is the certificate of capacity as it fulfils the requirements of the SRC Act.

A completed state  certificate of capacity or medical certificate or other medical certificate is also accepted if it meets the requirements of the SRC Act.

Certificate requirements

Information required

To help process your claim, a certificate of capacity or other medical certificate must:

• contain your details
• state the precise diagnosis
• describe your symptoms
• for physical injuries, state the date it occurred
• contain a review date and not be open-ended
• list the treatment required for the compensable injury or illness
• include your capacity for work and any modifications or restrictions in relation to your condition.

Specific requirements

The certificate of capacity or medical certificate must:

• contain the contact details of the legally qualified medical practitioner and their provider number
• be signed and dated by the practitioner who made the examination
• be the original (not a photocopied version).

Payment of the medical certificate fee

Your claims manager can arrange payment for the initial (first visit) certificate fee in New South Wales and the Northern Territory.

Other Australian states and territories incorporate the cost of certificates into their fee structures.

Medical examinations

Your claims manager may arrange for you to be examined by a legally qualified medical practitioner (LQMP) to assist with determining or managing your claim.

Your claims manager can request your treating practitioner or an independent practitioner, who has relevant qualifications in relation to your injury and has not treated you before, conduct an examination and provide a report.

Independent examinations

If your claims manager determines that you are required to attend an examination with an independent practitioner, they will contact you to confirm their intent to organise an independent medical examination and the reasons for this. Prior to booking the examination, your claims manager will discuss the appointment with you and consider your preferences and needs. This may include:

• Your availability to attend the examination including the date range and preferred time of day.
• Considering the nature of your medical condition, your preference in deciding between a face-to-face or video examination.
• There may be practical considerations or medical preference as to how the examination is undertaken and your claims manager should indicate if this is the case.
• If a face-to-face assessment is required, your case manager needs to consider any mobility restrictions and/or transport needs you have in accessing medical assessment.
• If a video examination is required ensure appropriate technical support is provided.
• Consider your preferences around having a chaperone, support person or interpreter present. Note there will also need to be consideration of the nature of the assessment and the requirements of the IME and the claims manager.
• Consider your preferences around the gender of the medical examiner.

Attending your examination

Once the booking has been made, your claims manager will confirm with you:

• the details of the booking including location, time, and the LQMP doing the assessment
• any transport or mobility assistance you require.

In the rare instances where long distance travel is required in order to attend a medical examination, this may include travel assistance such as providing details of flights and accommodation booked on your behalf.

Comcare will reimburse you for the cost of any reasonable travel expenses that you may incur in relation to your examination with the independent medical practitioner.

Please advise your claims manager if due to your compensable condition, you will be taking an escort with you to the examination or if you require a translator. Your claims manager will also contact your treating medical practitioner to advise them of the examination and invite them to provide any queries or questions in relation to your condition that would benefit from a specialist’s opinion.

The medical report from your treating practitioner or from the independent practitioner usually addresses a set of questions asked by your claims manager. Your claims manager may seek support from clinically trained Comcare staff around these questions.

Your claims manager uses the information in the report to determine liability and assist you to return to health and work.

If you have a complaint about your examination

If you are unhappy with the way a service has been delivered, or with how you have been treated, you have a right to complain and have your concern addressed.

You can raise your complaint directly with the independent medical examiner, or their clinic. If your appointment was managed through a medico-legal provider, you can raise your complaint with the provider.

If you are not comfortable raising your complaint with the independent medical examiner, their clinic or the medico-legal provider, or you feel your complaint has not been addressed, you can raise your complaint with the person that referred you to the examination (usually your claims manager or rehabilitation case manager).

If you have a complaint about the medical practitioner’s behaviour, such as a concern that their behaviour is placing the public at risk, they are practicing in an unsafe manner or their health may be affecting their ability to make safe judgements about their patients, you may raise your complaint through the Australian Health Practitioners Regulation Agency.

Medical reports

Medical reports explained

Medical reports describe your claimed injury or illness and are provided by a medical practitioner or a treating allied health professional.

Your claims manager may ask for a medical report to help with the management of your claim, recovery, or return to work.

Payment of the medical report fee

Your claims manager will arrange payment for the medical report they request to help manage or determine your claim.

To avoid unnecessary expense, we recommend you talk with your claims manager before you obtain a report.

In some circumstances, reports are received that were not requested. The report may have been arranged by someone other than your claims manager, such as you or your representative.

Your claims manager uses their discretion when deciding whether to pay for a report they did not request. They may consider whether:

• the cost of the report is reasonable
• the report provides relevant new information which helps manage your claim or determine benefits.

If your claims manager decides not to pay for this report, the cost of the report remains the responsibility of the person or organisation who requested it.

If this happens, your claims manager will:

• contact you or your representative
• provide reasons why the report will not be paid for.

A decision by your claims manager not to pay for a report is an administrative decision and not a determination under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act). This decision cannot be reconsidered.