Operational Guidelines: Occupational Injuries Benefit - Medical Care under the Occupational Injuries Scheme

BREXIT impacts

Ireland / United Kingdom Social Security arrangements from 1st January 2021

The European Union and the United Kingdom agreed a Trade & Cooperation Agreement which contains a Protocol on Social Security to take effect from 1st January 2021. The Protocol provides for a wide range of social security issues into the future. On the 31st December 2020, the Convention on Social Security agreed between Ireland and the United Kingdom was commenced. Together these Agreements ensure, that all existing social security arrangements for Irish & UK citizens are maintained into the future. Ireland as an EU Member State, will extend on a unilateral basis the advantages of the Convention to Union citizens, as required.

For Brexit-related information see:

• Item was unpublished or removed

For information on social welfare entitlements see:

• Brexit Information
• FAQs on DFA about Brexit

Medical Care is one of the benefits available under the Occupational Injuries Scheme. Under the Scheme payment is made in respect of certain medical expenses which are considered to be reasonably and necessarily incurred as a result of an occupational accident or development of a prescribed occupational disease, but only to the extent that such expenses are not covered under the Health Service Executive or under this department's Treatment Benefits Scheme.

Information Leaflet

The SW 34 information leaflet summarises this scheme.

Legislation

The main legislation covering this scheme is contained in Chapter 13 of the Social Welfare Consolidation Act 2005 as amended and SI No 102 of 2007 Social Welfare (Consolidated Occupational Injuries) Regulations 2007.

Administration

The Scheme is administered by:

Qualifying conditions

The Scheme only applies to Occupational accidents and prescribed occupational diseases under the Occupational Injuries Scheme. (See the Sections which deal with Injury Benefit and Disablement Benefit.)

The accident or disease must have arisen out of employment insurable at PRSI Class A, B, D, J or M.

In the case of Class B contributors, payment is only made in respect of the cost of treatment provided subsequent to 26 weeks from the date of accident or contraction of the disease.

Medical expenses covered under the Scheme

Payment is made in respect of treatment which is considered to be reasonably and necessarily incurred as a result of an occupational accident or of the development of a prescribed disease and is made only to the extent that such treatment is not covered under the Health Service Executive or under the department's Treatment Benefits Scheme.

Subject to these provisions, the following are the expenses covered under the Scheme:

• visits by or to a GP
• GP prescriptions
• certain medical and surgical appliances including prosthetic and aural appliances, prescribed by a GP including repair and replacement
• certain dental and optical treatment and appliances
• certain treatment by members of professions allied to the medical profession where prescribed by a GP such as chiropractors and acupuncturists. Treatments which are available under the Health Acts in a public hospital, for example Physiotherapy, X-ray, MRI Scan, Specialist Consultations are excluded from the Medical Care Scheme
• certain travelling expenses to and from the place where medical care is provided. If the person uses their own car, payment is made at a fixed rate per mile. If a taxi is used and if the department is satisfied that its use was necessary, payment of the full cost is met. Travelling expenses may be paid for travel to both public and private appointments

If the person needs ongoing treatment because of the occupational accident or prescribed disease, payment of medical expenses incurred will continue to be made under the Scheme.

Claims

A claim should be made within six weeks of the start of medical treatment. This is normally six weeks from the date of the accident or of the development of the disease. If a claim is made at a later date, payment can be made in respect of the treatment provided up to 12 months before the date on which the claim is made. (See Guideline "Claims and Late Claims" for more details on the further backdating of claims).

Claim forms are available from:

Documentary evidence of treatment provided must be submitted with the claim.

Investigation

In the majority of cases, a claim to Injury Benefit would already have been made and questions regarding the accident or disease would have been investigated as is described in the separate guideline "OIB/Injury Benefit". If a claim to Injury Benefit has not been made, the accident or disease will be investigated in a similar manner to that for Injury Benefit.

Questions as to whether certain treatments applied for should be covered under this scheme may be referred for the opinion of the department's Medical Advisor before a decision is made.

Decisions

There is no right of appeal on a claim to Medical Care to the independent Social Welfare Appeals Office but a request for an administrative review may be made to the Medical Care Section.

How payment is made

Payment is normally made directly to the person concerned. The preferred payment option is by Electronic Fund Transfer (EFT) directly into a Bank or Building Society account. Payment can also be made by cheque or in cash at a Post Office.

If necessary payment may be made to the Health Service Executive or to an employer, at the employee's request, if treatment expenses are covered by the employer.

• Return to scheme page.