Continued Reasonable Medical treatment

Date: April 10, 2025

Rope and Comcare [2023] AATA 3005.

Key Points:

• Ms Eleanor Rope sought compensation for three claims: reimbursement for a philosophy textbook, approval of attendance at the University of the Third Age (U3A), and approval for further psychological treatment.
• Comcare initially rejected all three claims, leading to the appeal before the Administrative Appeals Tribunal (the Tribunal).
• The Tribunal varied Comcare’s decision regarding the philosophy textbook, allowing reimbursement, but affirmed the rejection of the other two claims

Background:

Eleanor Rope has suffered from chronic pain and related psychological symptoms since a motor vehicle accident in 1987, which occurred while she was on her way to work. Over the years, Comcare had provided compensation for various treatments, but in recent years it took the position that further treatments did not offer discernible improvements.

In the present case, the applicant filed three claims seeking compensation for additional treatments aimed at managing her symptoms. Comcare rejected these claims, which led to this appeal at the Tribunal.

The Tribunal was tasked with reviewing the following under the Safety Rehabilitation and Compensation Act 1988 (SRC Act).

• Whether the applicant currently suffers from a psychological condition that continues to be materially contributed to by her former employment with the Commonwealth.
• Reimbursement of $20 for a philosophy textbook.
• Approval of classes at U3A (including yoga and philosophy).
• Approval for psychological treatment.

The Law:

Section 14 of the SRC Act provides that the employer is liable to pay compensation in respect of an injury suffered by an employee if the injury results in death, incapacity for work, or impairment.

A disease is defined under section 5B of the SRC Act as an ailment, or an aggravation of an ailment, which has been contributed to, to a significant degree, by the employee’s employment.

Under section 4 of the SRC Act, an ailment is defined as any physical or mental ailment, disorder, defect of morbid condition.

Pursuant to section 16 of the SRC Act, where an employee suffers an injury, an insurer is liable to pay for the cost of medical treatment obtained in relation to the injury, being treatment that was reasonable to obtain in the circumstances.

Under section 4 of the SRC Act, an ailment means any physical or mental ailment, disorder, defect or morbid condition.

Conclusion:

Comcare suggested that the original cause of the applicant’s condition had been displaced. However, the Tribunal considered that the applicant’s primary issue remained her perception of pain, which originated from her 1987 accident and subsequent workplace experiences. The Tribunal held that her employment continued to materially contribute to her current somatic symptoms disorder.

Philosophy Textbook

The applicant had attended practical philosophy classes recommended by her GP since 2012. Although Comcare initially denied reimbursement for a textbook used in 2019, it later conceded during the hearing that the textbook purchase was directly linked to her compensable condition.

Comcare consented to the Tribunal’s Decision to vary the original decision, allowing the $20 reimbursement for the textbook.

University Classes

The applicant had enrolled in U3A classes, including yoga, mindfulness, and philosophy, as part of her strategy to manage her chronic pain and psychological symptoms. Her GP had endorsed these classes, stating they helped her maintain her condition. However, Comcare argued that these classes were not goal-focused, and there was no evidence they empowered the applicant to self-manage her condition. Comcare further argued that the classes were more social and did not constitute reasonable medical treatment.

The Tribunal affirmed Comcare’s decision, agreeing that while the classes may provide temporary relief, they were not a reasonable medical treatment under the SRC Act because they did not improve her condition or reduce her reliance on medications.

Psychological Treatment

The applicant sought approval for additional psychological sessions. Comcare had previously funded psychological treatments but had ceased doing so after determining they were not effective in improving her symptoms and continuing treatment would only reinforce her dependency on external help. The applicant argued that without continued treatment, her condition would deteriorate further.

The Tribunal affirmed Comcare’s decision, concluding that the treatment was no longer reasonable or effective. It noted that while the applicant’s treating doctors supported further psychological treatment, there was no evidence of its long-term benefits, and the focus should be on promoting self-management.

Lessons Learnt:

The Tribunal emphasized the importance of demonstrating both the medical necessity and the effectiveness of treatments when seeking compensation under the SRC Act. The applicant’s claims for U3A classes and further psychological treatment were denied on the grounds that they did not constitute reasonable medical treatment, given their lack of effectiveness in empowering her to manage her condition independently. Treatment that induces a sense of dependence is, on the basis of this decision, likely to result in a finding that it is not reasonable medical treatment in all the circumstances.

Contact:

Download PDF here:  Rope and Comcare [2023] AATA 3005

« Back to Insights