Penrith man awarded cost of knee surgery after insurer denies claim

PUBLISHED 19 Feb 2016

One of our clients from the Penrith region was awarded the cost of surgery, along with weekly payments for any time taken off as a result of the surgery, after suffering an injury in the workplace.

Our client was employed as a roof plumber and at the time of injury was working on scaffolding. He was squatting down and as he rose he felt a painful cracking sensation in his knee. He initially had an arthroscopy on the knee before the injury deteriorated to a point where his treating specialists recommended he would require a total knee replacement.

Pending this recommendation, a request was put to the insurer, whereby the insurer declined to pay for the surgery as they deemed it was not work related, nor was the surgery reasonably necessary.

Approximately four years after the date of injury, the worker attended upon the solicitors at Gerard Malouf and Partners to see if he could claim the surgery. He had continued to work in his position, and had even gained a promotion during that time. The only issue was that of the surgery. Having regard to the medical evidence available, it was deemed that this man had a reasonable case, and his solicitors went about obtaining funding from the Workers Compensation Independent Review Office (WIRO) to fund the claim.

WIRO approved the funding, meaning they agreed to cover the costs of all medical reports and clinical records the solicitors required, as well as covering the costs of the solicitors professional fees.

Following the approval of funding, the solicitors at Gerard Malouf and Partners organised this client to see one of their specialists to comment on what caused the injury and whether the proposed surgery was necessary. Our specialist agreed with the need for surgery and therefore a claim was lodged with the insurer.

The insurer continued to deny the claim, and the matter proceeded before the Workers Compensation Commission for an Arbitration.

Prior to the Arbitration, the solicitors enlisted the assistance of a barrister. The cost of the barrister’s assistance was another cost covered by WIRO. On the day of Arbitration, the solicitor, barrister and client attended along with the insurer’s representative. Both sides put forward their arguments, and the Arbitrator made a decision on the merits of the case.

The solicitors of Gerard Malouf and partners were successful in arguing that the required surgery was reasonably necessary as result of an injury that was caused during the course of employment. The insurer was ordered to pay for the cost of the surgery.

The achieved result was the one that our client was looking for. He is now able to receive the surgery he requires to be able to properly recover. At Gerard Malouf and Partners we understand the difficulties in dealing with these situations alone and are happy to be able to assist in these matters. A work injury often brings about a very stressful period in life, and the solicitors at GMP are able to assist in shouldering that burden.

Call us now on 1800 004 878 to book a free appointment with one of my compensation experts, or email your enquiry.