For many injured workers, the first major disagreement with the insurer is not about weekly payments. It is about treatment.
You may need physiotherapy, specialist appointments, scans, surgery, psychology, rehabilitation, medication or travel to medical appointments. The insurer may delay approval, ask for more information, or refuse to pay.
In NSW workers compensation claims, these disputes often fall under section 60 of the Workers Compensation Act 1987 (NSW). Section 60 says that if medical treatment is reasonably necessary because of a work injury, the employer or insurer may be required to pay for it.
But that does not mean every treatment cost is automatically covered.
What Does Section 60 Cover?
Section 60 covers more than standard doctor appointments.
It can include:
- GP visits
- specialist reviews
- scans and imaging
- physiotherapy
- psychology
- surgery
- hospital treatment
- ambulance services
- rehabilitation services
- treatment-related travel expenses
For example, if a worker injures their back lifting at work, section 60 may cover GP appointments, scans, specialist reviews, physiotherapy, pain management treatment and travel to those appointments, if those costs are reasonably necessary and properly linked to the work injury.
If a worker develops psychological symptoms because of a workplace incident, section 60 may also become relevant to psychology or psychiatric treatment.
The Key Test Is “Reasonably Necessary”
The most important phrase in section 60 is reasonably necessary. That does not always mean the treatment must be the only possible option. It also does not mean the insurer can reject treatment just because it is expensive or because recovery is taking longer than expected. The real question is whether the treatment is reasonable and needed because of the work injury.
For example, surgery may be reasonably necessary if medical evidence shows that conservative treatment has failed and the surgery is directed at the accepted work injury.
Ongoing physiotherapy may be reasonably necessary if it helps the worker improve movement, manage pain, build strength or return to work safely.
But treatment may be disputed if the insurer says it is not connected to the work injury, is not supported by medical evidence, or is unlikely to help.
Why Insurers Refuse Treatment
Even when a compensation claim has been accepted, treatment disputes can still happen.
An insurer may refuse payment because it says:
- the treatment is not reasonably necessary
- the treatment is not related to the accepted injury
- the treatment was not approved before it was provided
- the provider is not appropriately qualified
- the treatment is excessive or ongoing for too long
- there is not enough medical evidence
- the injury has resolved or improved
- another condition is causing the need for treatment
For example, an insurer may accept that a worker injured their shoulder, but refuse surgery if it argues the surgery is mainly for age-related degeneration rather than the work injury.
Another common example is physiotherapy. The insurer may pay for initial sessions, then later argue that more treatment is not reasonably necessary unless the treating doctor or physiotherapist explains why it is still needed.
Pre-Approval Can Matter
Some treatment may need insurer approval before it is provided. SIRA’s workers compensation guidelines explain that certain treatment and services can be provided without pre-approval, including some initial treatment and nominated treating doctor consultations. But not every type of treatment is exempt.
That means approval can matter, especially for surgery, extended allied health treatment, rehabilitation programs or more costly procedures.
For example, if a worker books surgery before the insurer has approved it, the insurer may later argue that it is not required to pay. That does not always end the issue, but it can make the dispute harder.
The safer approach is usually to make sure the request is supported by clear medical evidence and submitted through the proper approval process before treatment goes ahead, unless the treatment falls within an exemption or is urgent.
Approval Is Not the Same as Entitlement
Workers sometimes think that if the insurer refuses approval, the matter is over. That is not always true. A refusal means the insurer does not currently agree to pay. It does not necessarily mean the worker has no legal entitlement.
Section 60 decisionscan be challenged. The issue is whether the insurer’s decision is legally and medically sound.
For example, if a surgeon recommends an operation, the insurer may refuse it after obtaining its own medical opinion. The worker may still be able to challenge that refusal if the evidence shows the surgery is reasonably necessary because of the work injury.
Evidence Usually Decides the Dispute
A section 60 dispute is rarely won by simply saying, “I am still in pain.” Pain matters, but the evidence usually needs to go further. Strong evidence should explain:
- what treatment is being requested
- what injury it relates to
- why the treatment is needed
- what the treatment is expected to achieve
- why other options are not enough
- whether the treatment may help recovery or return to work
- whether the provider is appropriately qualified
- whether the cost and timing are reasonable
For example, a short note saying “physio required” may not be enough if the insurer is questioning ongoing sessions.
A stronger report may explain the worker’s current restrictions, the progress made so far, the treatment goals, the number of sessions requested, and how the treatment supports recovery or safe return to work.
Practical Examples
A worker with a knee injury may need an MRI, specialist review and surgery. If the medical evidence links those steps to the workplace injury and explains why they are needed, the treatment request is likely to be stronger.
A worker with a back injury may need ongoing physiotherapy. If the physiotherapist explains the treatment plan, goals, progress and expected benefit, the claim for further sessions may be better supported.
A worker with a psychological injury may need therapy. If the treating psychologist or psychiatrist explains how the treatment relates to the work injury and why it remains necessary, that can help respond to insurer objections.
A worker who needs to travel a long distance for specialist treatment may also be able to claim reasonable travel expenses, where those expenses are properly connected to the treatment.
Treatment Must Be Linked to the Work Injury
A key issue is whether the treatment is connected to the accepted workplace injury. This can become complicated where the worker had a previous condition, age-related changes, or a later injury.
For example, a worker may have had mild back degeneration before the workplace incident. The insurer may argue that treatment is needed because of the pre-existing condition. The worker may argue that the workplace injury aggravated the condition and caused the need for treatment.
Those disputes often require careful medical evidence. The question is not always whether the worker had any previous issues. The question is whether the work injury caused or contributed to the need for the treatment being claimed.
What to Look for in a Refusal Letter
If the insurer refuses treatment, the letter should be read carefully.
It may say the treatment is:
- not reasonably necessary
- not related to the accepted injury
- not properly requested
- not supported by medical evidence
- not approved in advance
- outside the guidelines
- based on a disputed diagnosis
Those reasons matter because they show what evidence may be needed to challenge the decision. For example, if the insurer says the treatment is not linked to the injury, the response may need stronger medical evidence on causation.
If the insurer says the treatment is not reasonably necessary, the response may need a clearer explanation of the treatment goals, expected benefit and why the treatment is appropriate.
Getting Legal Help Can Make a Difference
Section 60 treatment disputes can become technical quickly. The insurer may use language about reasonable necessity, pre-approval, causation, provider qualifications or the workers compensation guidelines. For an injured worker, that can be difficult to respond to without knowing what evidence is needed.
Law Advice assists injured workers by reviewing treatment refusals, identifying gaps in the medical material, obtaining supporting evidence, and challenging insurer decisions where treatment should be funded.
If an insurer is refusing to pay for treatment connected to your work injury, legal advice can help clarify whether the refusal is valid and what steps may be available to challenge it.