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 SRC Act , 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. Claims Manager considers that the information on your claim file or the information the Claims Manager is able to obtain from your treating medical practitioners is insufficient or inconsistent. Comcare will only arrange for an independent medical examination when all other methods of obtaining the required medical information have been exhausted.

Independent examinations

When there is inconsistent or insufficient medical information on the claim to make a decision, your Claims Manager may determine that you are required to attend an examination with a medical practitioner.

Prior to booking the examination, your Claims Manager will contact you to discuss the examination.

Your Claims Manager will discuss with you:

• the purpose of a medical examination and why it is required
• the type of speciality the medical examiner will need to conduct the examination
• the selection of the best suited medical practitioner to conduct the examination
• your availability to attend the examination including the location, 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, any mobility restrictions and/or transport needs you have in accessing medical assessment
• If a video examination is required ensuring appropriate technical support is provided
• 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
• your preferences around the choice of the medical examiner, including cultural preferences.

If you disagree with Comcare’s selection of the medical practitioner/s to conduct the examination, you must provide your views in writing or verbally within 3 calendar days from the date of the request.

Frequency of examinations

Comcare cannot ask you to attend a medical examination for the same injury or disease more often than once every six months. There are some exceptions, including:

• another medical practitioner has recommended a further examination or re-examination.
• there has been a change in the ‘employee’s circumstances’ as defined in section 4 of the Guide.
• the injury requires multidisciplinary medical treatment (i.e. a complex case) and it is appropriate for us to require you to undergo more than one examination, with a different medical practitioner.
• the assessor fails, for any reason, to provide a written report.
• a request for a reconsideration of a determination is made but a reviewable decision in response to that request has not yet been made.
• an application for review of a reviewable decision is made to the AAT but a final decision has not yet been made.
• you do not undergo the examination or obstruct the examination
• you or your treating practitioner request an examination

Attending your examination

Once the booking has been made, your Claims Manager will send a section 57 medical examination determination which includes:

• the details of the booking including location, time, and the LQMP doing the assessment
• the purpose and reasoning of the medical examination and the choice of the examiner
• your rights and obligations relating to the examination
• information regarding your attendance at a medical centre

In the rare instances where long distance travel is required in order to attend a medical examination, the letter may include information about 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 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.

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.

Your rights in relation to a medical examination

If you disagree with the Claims Manager’s determination that you are required to attend a medical examination, you may request a reconsideration of the determination. If you disagree with the reconsideration of the determination, you may ask for review at the Administrative Appeals Tribunal.

If you have a complaint about your examination

You can contact the person that referred you to the examination (usually your claims manager or rehabilitation case manager). You can also call Comcare on 1300 366 979 and ask for the Complaints and Feedback team or submit written feedback to Comcare via the online form or by emailing feedback@comcare.gov.au

Other options for raising your complaint include:

• 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 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.

For further information regarding medical examinations, please visit Scheme guidance - Section 57 power to require a medical examination under the SRC Act

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 SRC Act. This decision cannot be reconsidered.