TAC entitlement to medical and like expenses after a motor vehicle accident
The Transport Accident Commission (TAC) in Victoria provides crucial support to individuals injured in transport accidents. However, understanding the intricacies of medical and like expense entitlements provided when you make a TAC claim can be difficult. This blog aims to provide clarity on your entitlements, empowering you to access the support you deserve.
What are medical and like expenses in your TAC claim?
Medical and like expenses encompass a broad range of costs associated with your injuries resulting from a transport accident. This extends beyond traditional medical treatment to include services that assist your recovery and rehabilitation. Crucially, the TAC's focus is on funding "reasonable and necessary" expenses.
Categories of expenses in a TAC claim
While medical and like expenses can encompass a range of different expenses, they usually fall into one of the following categories.
Medical treatment
Medical treatment covered by the TAC includes consultations with doctors, specialists, surgeons, and other allied health professionals such as physiotherapists, psychologists, and occupational therapists. The TAC also covers hospital stays, emergency care, and ambulance services.
It is important to note that the TAC generally requires referrals from your treating doctor to enable them to reimburse you for specialist appointments.
To ensure reimbursement, you must ensure all treating professionals are registered with the Australian Health Practitioner Regulation Agency and that they provide detailed invoices regarding the services they provide you.
Rehabilitation services
Rehabilitation services are vital for regaining functionality and independence following a motor vehicle accident. These services encompass physiotherapy, occupational therapy, speech therapy, and various rehabilitation programs.
The overarching goal of rehabilitation is to restore you to your pre-accident level of function, or as close as is realistically possible.
Pharmaceuticals and medical supplies
The TAC covers the cost of prescription medications, pain relievers, and other necessary medical supplies related to injuries you sustained in a motor vehicle accident.
It is essential to ensure your doctor prescribes these items, and that you maintain detailed receipts for all purchases.
Travel expenses
Travel expenses to and from medical appointments, rehabilitation sessions, and other TAC-related activities are reimbursable.
This reimbursement includes mileage, public transport costs, and taxi fares.
To ensure reimbursement, you must maintain accurate records of your travel, including dates, distances, and costs.
Domestic assistance and personal support
If injuries you sustain in a motor vehicle accident prevent you from performing household tasks, the TAC may fund domestic assistance, which includes cleaning, laundry, and meal preparation.
Personal support, such as assistance with showering and dressing, may also be available. Access to these services is often facilitated after an occupational therapy assessment.
Care to support daily activities is only paid for by the TAC if necessary. There are limitations on how much attendant care the TAC will provide. They will only pay for up to 40 hours per week for any combination of attendant care services, childcare and home services (cleaning and gardening).
Domestic assistance and personal support will also only be paid for up to 5 years from your accident unless you have a severe injury. A severe injury refers to a significant brain injury, paraplegia, quadriplegia or amputation of a limb or burns to more than 50 per cent of the body.
Psychological services
Recognising the significant psychological impact of a transport accident (including for those who witness a road accident and are eligible to make a TAC claim for nervous shock), the TAC funds psychological treatment, including counselling and therapy.
These services can assist with conditions such as PTSD, anxiety, and depression.
Equipment and assistive devices
Depending on the severity of your injuries, you may require assistive devices, such as wheelchairs, mobility scooters, or home and car modifications.
The TAC will assess your individual needs and determine the appropriate equipment to provide.
The "reasonable and necessary" test for TAC medical and like expenses
The "reasonable and necessary" test is the cornerstone of how the TAC determines which medical and related expenses it will fund. It's not a rigid formula but rather a set of principles that guide their decision-making.
How are “reasonable” TAC medical and like expenses assessed?
To claim TAC medical and like expenses, the expense must be appropriate for your injuries and consistent with accepted medical practices.
Factors that influence reasonableness include:
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- Evidence-based medicine: Is the treatment supported by scientific research?
- Clinical appropriateness: Is the treatment suitable for the specific injuries and the individual's condition?
- Proportionality: Is the cost of the treatment in line with the expected benefits?
How are “necessary” TAC medical and like expenses assessed?
To claim TAC medical and like expenses, the expense must be directly related to your accident injuries and essential for your recovery. This involves establishing a clear causal link between the accident and the need for the expense.
Key considerations include:
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- Medical necessity: Is the treatment essential for the individual's recovery or rehabilitation?
- Functional impact: Does the treatment address limitations or impairments caused by the injuries?
- Alternatives: Are there less costly but equally effective alternatives available?
To demonstrate that an expense meets the criteria of both reasonable and necessary, the TAC will rely on medical reports and assessments from treating doctors and specialists. These reports should clearly document the injuries, the need for the proposed treatment, and the expected outcomes.
Rehabilitation plans and treatment protocols can also help to outline the goals of treatment and track progress. These plans provide evidence that the treatment is focused on improving the claimant’s functional abilities.
The TAC may request an independent medical examination (IME) to obtain an objective assessment of the injuries and the need for treatment. To find out more about what to expect from an IME appointment, read our blog “Independent Medical Examinations (IME) – WorkCover and TAC claims”.
Navigating the TAC claims process
If you have sustained an injury as a result of a motor vehicle accident, you should lodge a TAC claim as soon as possible after the accident or become aware of your injuries.
TAC claims can be lodged in three different ways.
- You can lodge your claim by completing the TAC’s online lodgement form;
- You can also lodge your claim over the phone by contacting the TAC on 1300 654 329; or
- If you were admitted to hospital after your accident, the hospital may have lodged a claim on your behalf. You should check with the hospital or the TAC to confirm that the claim has been lodged.
Timeframes when claiming TAC medical and like expenses
With an accepted TAC claim, you're entitled to reasonable medical and like expenses for your accepted injuries. For the first 90 days post-accident, you will not need to seek approval for the expenses related to your treatment, if they are recommended by your GP or doctors.
Beyond the initial 90-day window, your doctors must seek TAC approval for all necessary and reasonable treatments related to your injuries.
Appealing decisions by the TAC
Occasionally, the TAC may issue decisions that appear unfair, unreasonable, or that you simply disagree with. This could involve the denial of expenses related to your treatment, such as medication or surgical intervention, refusal to cover injury-related expenses, such as home assistance, or even the rejection of your entire claim. If you find yourself in this situation, getting immediate legal advice is crucial.
Notably, you only have 12 months to appeal an adverse TAC decision so it’s important to act fast.
You can learn more about appealing a TAC decision in our earlier blog, “Can I appeal a TAC decision I don’t agree with?”
Get help from a TAC lawyer?
Guardian Injury Law will provide clear guidance on your TAC rights and entitlements. We can assist you when first lodging your claim and ensure you receive all the compensation you deserve, not just what’s offered to you in the first instance.
If your claim is denied or you receive any other adverse decision, we can assist you with appeal options, the process involved, and potential outcomes, supporting you through every step.
Contacting Guardian Injury Law
This article is of a general nature and should not be relied upon as legal advice. If you require further information, advice or assistance for your specific circumstances, please contact Guardian Injury Law.