Hello,
For antenna design, it is not important, but for the link budget calculation it can be of prime importance.
As davenn says, you need higher masts to get LOS over real earth then when assuming flat surface.
As long as your propagation problem is well within the line of sight distance, you can ignore it. For TV you can't ignore it as TV towers normally cover large distance. In case of interference calculations (for frequency sharing), you can't ignore it also, as propagation beyond line of sight is dominated by diffraction over curved earth (and not to forget tropospheric ducting/scattering/etc).
With regards to reflection, you can assume flat earth to calculate reflection coefficients (for example using the Fresnel reflection formulas) in case of ground-ground communication. In case of significant height above ground (for example sattelites), you need to take into account that after reflection the radiation spreads out due to the curvature.