Does TAC Pay for Surgery After a Transport Accident?

Victims of motor vehicle accidents commonly need surgery to address their injuries. Some of the most common surgeries performed after a transport accident include:

• Emergency surgery to stop internal bleeding and repair damaged organs
• Surgery to repair broken bones
• Procedures on the neck and back, including repair of fractured vertebrae, removal of damaged discs, and spinal fusion
• Repair and replacement of damaged joints such as the knee, ankle, hips, etc.
• Surgery to relieve swelling in and around the brain
• Reconstructive dental surgery
• Plastic and reconstructive surgery for disfiguring injuries and scarring

Many of these surgeries occur immediately after your accident in the initial trauma hospitals. Payment for these surgeries by TAC is usually automatic.

The obligation to pay for surgeries that relate to injuries arising from your accident continues for the rest of your life. It is part of the no-fault accident benefits made available through the legislation that created the Transport Accident Commission (TAC).

With the passage of time, TAC unfortunately denies legitimate requests for surgeries and other procedures recommended by a health professional.

Henry Carus + Associates are proud to offer TAC clients a FREE Medical + Like Services Support Service. If the TAC will not pay for a surgery or another medical treatment or service you need, we are willing to review TAC’s decision and, if we believe it should be challenged, do so on your behalf without seeking payment of legal fees from you.

When Is Surgery Covered by the TAC?

The aftermath of a road accident is frightening enough without having to worry about what expenses will and will not be covered. Surgical procedures are among the medical expenses and supports covered by the TAC after an accident, subject to the following conditions:

90 Days After a Transport Accident

Prior approval by the TAC is not required for surgeries performed in the first 90 days following a road accident. The TAC will pay for the procedure(s) provided that:

• You have lodged a TAC claim and received a TAC claim number
• The surgery is related to your injuries from the transport accident
• Your doctor or another healthcare professional recommends the surgery

These conditions apply to both emergency surgeries as well as elective surgeries (non-emergent procedures that support your health and quality of life).

More Than 90 Days After a Transport Accident

Approval by the TAC is required for surgeries performed more than 90 days from the date of the motor vehicle accident. The first step of the approval process is to make an appointment with your doctor to discuss the procedure and get a referral to a surgeon.

Next, you will need to schedule an appointment with the surgeon. During this first visit, ask the surgeon to write to the TAC on your behalf outlining the reasons the surgery is necessary, what rehabilitation you will need after surgery, and any limitations you may face after the procedure.

The TAC will review the surgeon’s recommendations and decide whether to approve the surgery. If the surgery and associated supports and services are approved, you can move forward with scheduling the procedure.

Surgery for Severe Injuries After a Transport Accident

Surgical procedures are pre-approved by the TAC for clients who suffer what is legally defined as a “severe injury.” The TAC defines severe injuries as follows:

• A traumatic brain injury
• Paraplegia (paralysis of the legs and lower body)
• Quadriplegia (paralysis of the body below the neck)
• Loss of a limb
• Burns covering more than 50% of the body, OR
  “burns to not more than 50 percent of the body that cause severe disfigurement and comprise of full thickness burns: 
  • “to the head, neck, arms or lower legs; or
  • “that result in severe difficulties in performing mobility, communication and self care tasks”
• Injury to the brachial plexus (nerves in the shoulder) “that results in the loss of the use of a limb”
• Permanent blindness; the TAC has adopted the definition of permanent blindness found in Regulation 5 of the Victoria Transport Accident Regulations 2017:
  • “a field of vision that is constricted to 10 degrees or less of arc from central fixation in the better eye, irrespective of corrected visual acuity; or
  • “a corrected visual acuity of less than 6/60 of the Snellen Scale in both eyes; or
  • “a combination of visual defects resulting in the same degree of visual loss”

If you need surgery to treat one or more severe injuries from a road accident, necessary procedures are pre-approved by the TAC for up to 1 year from the date of the accident.

What Surgical Costs Are Covered by the TAC After a Transport Accident?

TAC no-fault benefits cover all costs for surgeries related to injuries from the accident. These include:

• Surgical fees
• Fees for other providers involved in the surgery
• Anaesthesia
• Operating theatre fees
• Hospitalisation fees up to 24 hours prior to surgery and during recovery
• Fees for inpatient services while you are in hospital

Costs related to therapy and rehabilitation after surgery (inpatient and/or at home) are also covered by the TAC.

Why Would the TAC Refuse to Pay for Surgery After a Transport Accident?

Sometimes the TAC will deny surgery benefits on medical grounds. The TAC has an internal Clinical Panel advisor process that may lead to the TAC questioning whether the surgery relates to a TAC accident injury or whether the surgery is reasonably needed. If this is the case, you have several options for disputing the TAC’s decision:

• Lodge a request with the TAC for an informal review of the decision
• Retain a lawyer to lodge a dispute application on your behalf
• Apply for a review of the decision by the Victorian Civil and Administrative Tribunal

Unfortunately, the TAC’s reasoning in denying a surgery can be difficult to understand, especially when the letter advising you of the decision does not give you all the details of how the TAC came to its decision. If a procedure recommended by a medical professional is denied or your TAC benefits are suddenly reduced or terminated, it is crucial to seek legal guidance as soon as possible.

TAC Won’t Pay for Surgery? Henry Carus + Associates Can Help

Henry Carus + Associates have extensive experience with TAC-related matters. Many times we can form an initial opinion that the TAC decision is questionable. We thereafter go to your treating doctors to confirm why they say the surgery is needed. We then turn to the TAC’s own claims file to follow the process of how the TAC reached its decision.

Many times with the support of just your own treating doctors, we are able to have TAC withdraw its denial and accept the recommended surgery. If needed, we also rely on our own independent medical practitioners (usually surgeons in the medical field in question) to advise us and give support to the treating doctor’s request for the surgery.

We seek to do all of the above with speed. Many times the surgery is urgently needed and should not be delayed at a time when you truly need to maintain your health and quality of life. It is fair to say that the TAC accident will have already turned much of your world upside down.

If you or someone you love is facing a denial of needed surgery, Henry Carus + Associates can help.

The lawyers at Henry Carus + Associates have unparalleled experience with the complex TAC legislation in Victoria. This experience enables us to offer a unique Medical Care + Like Services Support Service. If the TAC will not pay for surgery or other entitlements, our team will work on your behalf to resolve any disputes and get your benefits paid. We provide this service FREE to all TAC clients. We will seek our legal costs only from the TAC.

Please contact Henry Carus + Associates by calling 03 9001 1318 today for a free, no-obligation consultation. Our transport accident lawyers serve clients in Melbourne and throughout Victoria.