Does TAC pay for surgery?
Yes, in some cases the TAC will pay for the cost of surgery if you have an accepted TAC claim.
Within 90 days of the accident
If you need surgery within 90 days of the accident, you just need to have an accepted TAC claim and the surgery needs to be recommended by your specialist or other doctor for the treatment of an injury or injuries suffered in the accident.
Importantly, you do not need to contact the TAC and ask for their approval to pay for the surgery.
It’s also important to keep in mind that the TAC will be responsible for paying post surgical rehabilitation expenses such as physiotherapy treatment.
After 90 days of the accident
If you’re surgery request falls more than 90 days after the accident, then you will need to get approval from the TAC to pay for the surgery.
What usually happens is a general practitioner will provide you with a referral to a specialist doctor.
The specialist doctor will then need to send a request for surgery to the TAC.
In some cases the specialist will send the request to the TAC directly (ensure they have your TAC claim number) and in other instances they will provide you with the request and ask you to send it off to the TAC.
Any requests for surgery needs to explain what the surgery is, why it is required to treat the injury or injuries suffered in the accident. It should also detail what limitations you may have after surgery and what services you may require after surgery in terms of rehabilitation.
Once the TAC has a request for surgery, they will then need to make a decision in relation to whether to approve the surgery or not.
Unfortunately, the TAC’s processing time relating to surgery determination can be many months.
However, if you do not hear from TAC within a few weeks after the surgery request has been submitted you should follow them up and ask them to provide you with an update and whether you might be able to assist, for example by providing further information.
Sometimes the TAC will make a decision based on the medical material that they have and the request from your specialist.
Other times, they may request further information from your treating practitioner/s. They may call or write to your doctor and ask them specific questions.
They may also refer your request to what is called the TAC clinical panel.
Basically, the TAC have a number of doctors that they can ask questions of.
So they may ask the doctor for their opinion in relation to the surgery and the doctor will generally provide a written response with their opinion.
If the TAC approve surgery
They will send you a letter confirming that they will pay for the surgery.
You should then telephone your surgeon and advise them that TAC has approved payment for the surgery and request that the appropriate arrangements be put in place for you to have the surgery.
In some instances if a long period of time has passed since you last saw the doctor, the doctor may want to see you again before scheduling the surgery.
The TAC will pay for:
They will pay for the surgery which includes any anaesthesia which may be required.
The TAC have a fee schedule relating to specific surgeries.
And this is important. They will only pay set amounts for specific surgeries.
Many surgeons will limit their bills to ensure you do not have to pay over and above the set fees.
However, other surgeons will not and if a further amount is owed you will need to pay the difference.
It would be a good idea prior booking the surgery to contact the TAC and ask them about their scheduled fees relating to the surgery that you are going to have and then contact your provider and ask them about their fees.
If the TAC reject surgery
If the surgery request is rejected then you can appeal the decision.
You can read this page which goes through the options you have to appeal this decision.
We would recommend engaging a lawyer and pursuing a dispute application as the first port of call.
The TAC should give specific reasons as to why the surgery has been rejected and you should consider discussing these reasons with your surgeon and perhaps he or she may be able to assist you by providing further comment that will help you to contest the TAC’s decision. If you have a lawyer they should look after this for you.
Conclusion
The TAC will pay for surgery in many instances.
You would need to have an excepted TAC claim.
If the request for surgery occurs within 90 days after the accident, you do not need to obtain approval from the TAC to have the surgery.
If the request for surgery occurs outside 90 days from the accident, your specialist who wants to perform the surgery will need to send a request for surgery to the TAC.
The TAC will then need to determine whether to accept or reject the surgery request.
If you do not hear from the TAC within a few weeks after you submit the surgery request you should call them and follow them up.
If they accept the request then you can go ahead and book the surgery.
If they reject the request then there are appeal avenues open to you.
Keep in mind that the TAC will only pay set fees for specific surgeries so before you schedule the surgery you should contact the TAC find out how much they will pay for a particular. You should then contact your provider and ask them what their fees will be.
Many providers will bill only what the TAC will pay for however some providers will bill more than this and you would need to pay the fee that the TAC does not cover.
