Understanding the 52-Week Medical and Like Entitlement Review for Injured Workers

If you are an injured worker who has resumed full-time employment or are no longer entitled to weekly payments, your managing agent will notify you about a review approximately 52 weeks after your payments have ended. This notification, usually through a letter or a phone call, indicates that your claim is being reviewed as part of the 52-Week Medical and Like Entitlement Review process.

This review means your managing agent is evaluating the necessity of your ongoing treatment and related services. This process may come as a surprise to many.

Here’s a guide to help you understand the process more clearly.

Understanding Ongoing Entitlement and the 52-Week Rule

Determining Ongoing Entitlement

Compensation for medical and related services will cease under the following conditions:

• 52 weeks after your entitlement to weekly payments ceases, unless exceptions apply.
• 52 weeks after your entitlement to medical and related services arises, if your claim was accepted for these services only, unless exceptions apply.
• 13 weeks from the date you became entitled to provisional payments, if your mental injury claim was rejected.

The 52-Week Medical and Like Entitlement Review (MLER)

When a claim reaches 52 weeks post:

• The cessation of weekly payments (return to full-time work, a certificate of capacity reflecting capacity for pre-injury employment, or termination of weekly payments).
• The entitlement to medical and related expenses first arising in a medical expenses-only claim (date of first approved service).

At this point, the claim undergoes a Medical and Like Entitlement Review (MLER). During this review, agents determine whether medical and related benefits should cease or if any exceptions apply that allow these benefits to continue.

What This Means for You

Once your entitlement to weekly payments ceases, a year later, you may be reviewed under this legislation. If you never had an entitlement to weekly payments (never lost time off work due to your injury), you will be reviewed a year after your Date of Injury or claim lodgement.

These reviews can begin at any point leading up to or after the 52-week period has lapsed. It is not uncommon to have several of these reviews over the life of your claim if you continue claiming medical and related treatment for an extended period.

Exceptions Excluding a Claim from the MLER

Your medical and related benefits will not be affected by the 52-week rule if you:

• Have received common law damages for economic loss in respect of the same claim, even if paid by TAC.
• Accept a voluntary settlement of weekly payments under the legislation.
• Made a weekly payments claim before 12 November 1997 and have been assessed as having a ‘serious injury’ (30% whole person impairment).

Note that if you have been issued a serious injury certificate but have not had a payment for economic loss or received an Impairment Benefit payment, you will still be eligible for this review for claims lodged after 12 November 1997.

Additional Considerations for the MLER

Medical and related benefits may continue beyond 52 weeks if:

• You have returned to work but cannot remain at work without the service.
• You have returned to work but require surgery.
• You need a prosthesis modification.
• The service is essential to ensuring your health or ability to perform necessary daily activities does not significantly deteriorate.

To determine if these circumstances apply, an MLER may be required. The questions in the MLER process must be answered as of the date the agent completes the review, not the date the MLER process was initiated.

What the Review Looks Like for You

If your claim is flagged for the 52-Week Medical and Like Entitlement Review, you will generally receive a phone call from your managing agent advising you of this review. If you are uncontactable, appropriate attempts should have been made and documented.

Once contacted, or after appropriate attempts to contact you, you will receive a letter advising you of the review and a questionnaire.

Your treating health providers will also receive separate questionnaires. These are only sent to your active treaters. For example, if you are seeing your physiotherapist and general practitioner but have not seen other treaters for over 3 months, questionnaires would only be sent to your physiotherapist and general practitioner.

All parties will be given a timeframe to complete these questionnaires, normally around 6 weeks. This can be extended based on extenuating circumstances, such as your GP being on annual leave or awaiting further medical information like an MRI.

Once all information has been completed and received, your managing agent will review it to determine whether treatment should continue. If the information has not been received and appropriate follow-ups have been documented, the agent may make a decision without it.

It is crucial that all relevant parties supply the necessary information promptly to ensure an appropriate decision is made.