How we make decisions
In the first 90 days after your accident:
- there are some treatments and services the TAC can help pay for
- you don't need to contact us for approval for these treatments and services.
We can do this because we have a good understanding of the types of treatments and services most people need after an accident.
90 days after your accident, if you need more treatments and services, we will ask you and your providers for information. This helps us understand more about your injuries and the treatment and support you need. We also use this information to make decisions about what we can help pay for, and for how long.
When we make a decision about paying for a treatment or service, we consider the following:
1. Does the person have an entitlement under the Transport Accident Act, 1986 (the Act)?
The Act sets out the definition of a transport accident and who is eligible for TAC support. It tells us what things we can and can’t help pay for. It also tells us how long we can help pay for certain things.
In general, the Act says we can help pay for ‘medical and like’ services related to a person’s transport accident injuries.
For example, if a person has a soft-tissue injury because of a transport accident and they need to see a physiotherapist, we can help pay for this treatment.
If they need more than 5 days off work because of their injury, we can pay some income support while they recover.
If a person is not entitled according to the Act, then we do not need to ask further questions to make a claim decision.
2. Is the request reasonable?
The Act also tells us that we must consider what is reasonable when we make a decision.
When we decide if something is reasonable, we look at 2 things:
- Is this treatment or service necessary in the circumstances and will it produce the intended result?
- Is the cost and duration of the treatment or service a reasonable amount, in relation to that service?
We have published the TAC rates that we consider reasonable for each treatment and service. You can see a list of TAC rates here.
3. Is the treatment or service clinically justified?
The TAC has a Clinical Framework that all TAC providers follow. The principles of the Clinical Framework make sure that a treatment or service is effective and has measurable results.
For example, we may look at whether a treatment is:
- recommended by a health professional
- is considered an effective type of treatment for the injury.
4. Is the treatment or service outcome focussed?
Outcome focussed means a treatment or service that helps a person achieve their recovery goals. When a treatment is outcome focussed, there are measurable results that can show if a person is making progress with that treatment.
We may contact a health provider to check a person’s progress and find out what support they need.
We may ask for a treatment plan or medical report from a health professional.
We may ask a TAC client to go to an independent medical exam to get a medical opinion about their injuries and treatment.
Understanding a TAC decision
We will always communicate our decisions in writing to you. This written communication will clearly outline the following:
- what the decision is
- what information we considered in making the decision
- how you can ask for a review of the decision.
If you are unclear about why or how the TAC made a decision on your claim, then you should contact us for clarification.
You also have the right to any information that we considered when we made our decision. Find out more about how to get a copy of your TAC documentation.
If you disagree with a TAC decision
TAC clients have several options if they disagree with a TAC decision. You can learn more about our review process here.