Eligibility for continuation of wages and medical benefits
Your entitlement to weekly and medical benefits is limited by workers compensation legislation.
Unless your injury results in an impairment assessment in excess of 20 per cent (whole person impairment), your entitlement to weekly benefit will cease after five years.
Your ongoing entitlement to receive medical treatment is also limited and is linked to the date your weekly benefits cease. Medical treatment costs can be claimed for a limited period following the cessation of your weekly benefit.
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Eligibility for continuation of wages post 260 weeks
Eligibility for continuation of medical benefits
Eligibility for continuation of wages post 260 weeks
Within Section 39 of the Workers Compensation Act 1987, weekly benefits are available for a maximum period of 260 weeks (five years). Section 39 applies unless an injured worker has a permanent impairment (WPI) of more than 20 per cent.
Note: Section 39 does not apply to exempt categories of workers such as police officers, paramedics or firefighters, coal miners, volunteers prescribed by the Workers Compensation (Bush Fire, Emergency and Rescue Services) Act 1987, or other voluntary work or unpaid employment.
When does the week count towards your 260 weeks start?
- For claims made prior to 1 October 2012 ('existing claims'), the week count starts from 1 January 2013.
- For claims made on or after 1 October 2012, the 260-week count starts on your first day of incapacity which is paid on the claim.
Permanent impairment
For most workplace injury claims, you won't need a permanent impairment assessment. Although, if your claim is reaching 260 weeks, the Claim Service Provider (CSP) will need to find out your level of permanent impairment to review if you can receive weekly payment beyond 260 weeks.
If you are assessed as having a whole person impairment (WPI) of 20 per cent or less, you are not entitled to payments beyond 260 weeks (five years) and the CSP is required to notify you of the remaining number of weekly benefits on your claim.
Claims Service Provider contact
Your case manager will keep you informed as you are approaching 260 weeks of weekly benefits. They will supply you with information regarding all weekly benefits that have been paid to you, how many entitlement weeks you have been paid and when your weekly benefits will cease.
In some cases, the case manager may indicate that an Independent Medical Examination is required to be able to confirm your permanent impairment percentage. If this is the case, your case manager will arrange the appointment and provide you with all necessary information for your attendance.
Once the Independent Medical Examination report is received, your case manager will communicate the particulars of the report and the result of permanent impairment and the resulting entitlement information.
If your permanent impairment percentage is less than 20 per cent, you should be provided with written notice at a minimum of 13 weeks prior to cessation at 260 weeks. This letter could be utilised to approach Centrelink.
If you have questions regarding Section 39 you should contact your case manager to find out more information.
What happens to my medical benefits?
If you have reached your maximum 260-week entitlements for weekly payments, you can continue to access reasonably necessary medical treatment dependent on your permanent impairment percentage.
My weekly benefits are coming to an end, what now?
If your weekly benefits are coming to an end, there may be other forms of support available. Please contact your case manager to discuss options which could be applicable to your current circumstances.
Back to top ⇡Eligibility for continuation of medical benefits
After your weekly benefits have ceased (aside from if your claim is disputed), you are still entitled to claim ongoing reasonably necessary medical benefits for a fixed period. The specific time differs depends on your assessed level of whole permanent impairment (WPI):
No assessment or WPI of 0-10%
For workers with no WPI assessment or permanent assessment as 0-10 per cent: Two years medical entitlement from when weekly payments stop, or from the date of claim if no weekly payments are made.
WPI of 11-20%
For workers with a WPI permanent assessment between 11-20 per cent: Five years medical entitlement from when weekly payments stop, or from the date of claim if no weekly payments are made.
High needs, WPI greater than 20%
For workers with high needs with a WPI assessment of greater than 20 per cent or if a medical assessor has declined to make an assessment as the worker has not reached maximum medical improvement (MMI).
In some circumstances, medical aids and applicable treatment can be considered a lifetime entitlement and are claimable for life. These benefits include home or vehicle modifications, crutches, eyes or teeth and other artificial aids such as hearing aids and hearing aid batteries.
What is the notice period?
You must be supplied with written notice before the end of your medical entitlements cease. Your nominated treating doctor and other treating parties must also be informed, to ensure they are aware that your medical entitlements are coming to an end.
You should be given notification at least 13 weeks prior to medical cessation.
What support services are available to me?
You may still require medical treatment after your medical entitlements cease.
Your medical and related treatment may be necessary to support wellbeing alongside rehabilitation and return to health.
Under these circumstances, your insurer should assist with providing the necessary support and ensuring you can access services through the public and private health system.
Resources: Where can you go for help?
Case manager
You can contact your case manager to discuss your current situation. The case manager will be able to create a tailored plan of transition from the scheme in conjunction with your treatment providers.
Your Claims Service Provider also has access to some valuable initiatives such as Community Support Services.
Nominated treating doctor, specialist or allied health treating provider
Your treatment team may be able to assist with your transition off workers compensation. Your doctor may be able to provide you with a mental health care plan, or access to other government-funded medical programs.
Financial support: Centrelink
If you are ineligible for weekly benefits due to Section 39, you should start your application for Centrelink 13 weeks prior to weekly benefits ceasing.
You should also source a letter from your insurer outlining how many weekly benefits have been paid, when your weekly benefits are ceasing and the reason for cessation of weekly benefits.
You may be required to supply Centrelink with up-to-date medical evidence and other supporting documents. You may also have to supply financial information such as any lump sums received, spouse earnings and so on.
Housing support
Housing pathways: if you require assistance with housing you may find it beneficial to contact Housing support.
Mental health support
If you require crisis or mental health support there are options available:
- Lifeline can assist with times in crisis and suicide prevention 24 hours a day.
- Beyondblue provides online support to assist with stressful circumstances.
- If you are suffering from a mental health condition and require support, you can contact Mental Health Line 24 hours a day on 1800 011 511.
- If you require support for an emergency, please contact 000.
