Time Limit to Apply for the Payment of Medical and Like Expenses

Policy

The TAC can fund the reasonable cost of medical and like expenses incurred in relation to a transport accident when the "application for payment" is made within:

  • 3 years of the date of the client's date of accident, or
  • 2 years of the date of incurring the expense in any other case.

Transport Accident Act 1986 reference: s.60(1A)

Definitions

In this policy:

  • 'date of application for payment' refers to the date that:
    • a telephone call is made to the TAC requesting payment
    • a letter or an electronic communication such as e-mail requesting payment is sent and received by the TAC
    • a client requests reimbursement or payment of expenses paid by him/her
    • a provider submits accounts for payment
    • a family member requests reimbursement or payment of expenses paid by him/her for travel and accommodation expenses

whichever is earlier.

  • 'Medical and like expenses' refers to the reasonable cost, expense or charge of:
    • road accident rescue, ambulance services and transportation costs
    • medical, hospital, nursing and or attendant care services
    • rehabilitation and disability services
    • housekeeping, child care and domestic services
    • counselling for nominated family members (as a result of the severe injury or death of a client)
    • burial or cremation services
    • travelling and accommodation costs incurred by a parent when visiting a dependent child in hospital
    • travelling and accommodation costs incurred by a member of the immediate family when visiting a client in hospital
    • travel to work costs
    • travel to medical and likes services
    • post hospital support costs such as those for loss of wages and child care
    • modifications or contribution to purchase cost of a motor vehicle or home
    • repatriation costs.

Note that the medical and like services must be received in Australia unless otherwise stated in the Transport Accident Act 1986.

Guidelines

Why is there a time limit to apply for payments of medical and like expenses?

In order to make an accurate assessment of liability in relation to funding medical and like expenses, the TAC expects applications for payment of expenses to be submitted with the TAC in a timely manner. Therefore, a time limit has been set in the legislation. A client therefore has either 3 years from the date of accident or 2 years from the date of receiving a medical or like service or incurring the expense in which to lodge an application for payment with the TAC.

Example 1. Within 3 years from the date of accident
The client had her accident on 21 February 2007 and received a medical service on the 22 February 2007, the treating medical practitioner or the client has until 21 February 2010 to lodge an application for payment of the account with the TAC. If the application for payment is made on or after 22 February 2010, the account will be denied as it is outside the 3-year time limit.

Example 2. Beyond 3 years from the date of accidentThe client had his accident on 16 October 2003 and received a medical service on 19 March 2008, the treating medical practitioner or the client has until 19 March 2010 to lodge an application for payment of the account with the TAC. If the application for payment is made on or after 20 March 2010 the account will be denied.

When did the time limit commence?

Section 60 of the Transport Accident Act 1986 places a time constraint in which medical and like expenses must be claimed with the TAC for payment. This time limit applies to all applications made for payment on and after January 2001.

How will a person be informed that his/her application for payment of an account or expense in relation to a medical and like service is denied because it falls outside of the time limit?

This will depend on the particular circumstance. If the accounts or expenses fall outside the relevant time limit, the TAC's payment system will automatically deny the accounts. A remittance advice is sent to the client or provider advising the account is denied as it is outside the time limit. Where appropriate, a letter in relation to denying the accounts may be sent stating the accounts can not be paid as they are outside the time limit.

Where any of the exceptions below apply, such as when a matter is resolved in the client's favour at VCAT and the TAC will pay accounts which are outside the time limit, a letter or other communication will also be used.

What if a client's medical and like expenses are lodged outside the time limit because the relationship between the injury and the transport accident was not established at a earlier time?

Where a link between the injury and the transport accident is established at a later time, the TAC can fund the client's medical and like expenses in relation to that injury only for:

  • 3 years prior to the date of application for payment if the link between the accident and the injury is made within 3 years of the date of the transport accident, or
  • the 2 years prior to the date of application for payment if the link between the accident is made after 3 years of the date of the transport accident.

Are there are exceptions to the time limit?

The following exceptions to the time limit may apply:

Medical Excess

How does the time limit apply where it may take more than 3 years from the date of accident for the client to reach the medical excess?

The time limit will not apply if it takes more than 3 years from the date of the transport accident for a client to reach the medical excess. Accounts submitted as part of the client's medical excess obligation which are more than 3 years old will be used to calculate the medical excess and the client will not be penalised.

Matters pending VCAT or Court Decisions

How does the time limit apply in cases when a service is denied, and an application for review is lodged at VCAT or another higher court of appeal?

If during the appeal process, the applicable time limit expires and if the review or appeal is decided in the client's favour, the  time limit will be ignored and the TAC can fund the costs incurred by the client for that particular service from the date of the TAC's denial to the date the appeal was resolved.

Example
The TAC denies physiotherapy treatment on 8 August 2005. The client lodges a VCAT review on 8 July 2006. The matter is decided in the client's favour by VCAT on 8 December 2007. The client is entitled to have his/her physiotherapy treatment paid by the TAC from 8 August 2005 to 8 December 2007, without regard to the normal time constraints imposed on medical and like expenses.

How long after an appeal matter is resolved should a client submit receipts and or accounts which fall outside the time limit?

A client should submit receipts and accounts that fall outside the applicable time limit within 28 days of the VCAT review decision. Where a client is unable to gather all the information within 28 days, usually because bulk accounts may need to be provided by the client's service provider, the client should contact the TAC to discuss and determine an appropriate timeframe.