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Home » Health Professionals » Injury Management- What is happening and When? » Key Things An Injured Worker Needs To Know

Key Things An Injured Worker Needs To Know

 

In the following document many of the issues an injured worker experiences are outlined. Suggestions are made of strategies the injured worker / your patient / client may be able to try to help to facilitate progress.  This information is also provided to employers - see “employer information files”, of strategies they can adopt to support their injured return to work. 

The issues workers and employers face are often the same or similar to those of their treatment providers and doctor.  The obstacles outlined and strategies suggested may help you better understand what may be happening to stakeholders in the workers compensation system at a given point in time. Ideas are offered for supporting the various stakeholders assisting injured workers recover and get back to work.

 

Reporting an Injury or Incident. Workplace injuries or Illnesses

     

If in the course of your work if you become injured (physically or psychologically, or contract an illness i.e. e.g. from toxic fumes), an injured worker is entitled to have the costs of your medical treatment and rehabilitation reimbursed through the compulsory workers compensation policy that your employer is required to have. In fact if the injury occurs at work The Federal Governments’ Medicare scheme or private health insurance may not cover them for treatment of the injury if you are entitled to workers compensation benefits.

 

Circumstances of injury  

 

Sometimes it is very clear that a work place injury occurred at the workplace and was a result of something that happened had work. For example if a worker falls off a ladder while helping several workmates load or unload tiles this is an obvious  claim. There are likely to be witnesses and there may be blood or an obvious fracture. 

 

At other times an injury may be less obvious such as with a repetitive strain injury, or a psychological injury related to bullying. These injuries may not have been witnessed by other staff or may have also have been associated with issues of performance management.

 

When an injury occurs and there is uncertainty as to whether it occurred at work, questions of liability for workers compensation claim may arise.  To minimise difficulties down the track with accessing treatment and workers compensation benefits it is important injured workers report incidents and injuries to their employer.  Employers are required to have procedures for reporting incident and injuries and in having procedures in place to either prevent injuries (Workplace Health and Safety) by investigating the incident and putting in place ways to avoid further risks/ matters.

 

Receiving Treatment

 

The first step in getting treatment or time off work to seek medical help for a workplace incident is the reporting of the incident to the employer. With traumatic incidents medical care and treatment is the priority. The next step may be a visit to a doctor.  An employer may request a worker to see a doctor of their choice.  The doctor is consulted for ongoing follow up treatment, the nominated treatment doctor (NTD), is the decision of the injured worker, not the employer or insurer.

Choosing a doctor (The Nominated Treating Doctor- NTD)

 

The NTD plays a key role in the management of an injury and how a claim is managed.  He or she assesses whether an injured worker is fit for work, and in what capacity. He or she can refer to various specialists for opinions and follow up.  It is a requirement for referral to most treatment providers such as psychologists, medical specialists and surgeons, to have been referred formally by the NTD.  Insurers must (unless they have good reason) support the recommendations for specialist referrals or treatment made by the NTD.

 

The medical certificate the NTD writes is a legal document that must be adhered to by all parties.  The employer must provide documented suitable duties consistent with the doctor’s certification.  The worker must attempt to perform them or risk having their benefits suspended.  

 

The workers compensation system is complex and not all doctors are familiar with all that is required of them.  Some do not like to undertake workers compensation work at all.  It is important when an injured worker is choosing a NTD to be aware of these issues and chooses a doctor that:

 

  1. Is experienced as a GP generally
  2. Has experience with managing compensation claims
  3. Has empathy and understanding of the issues associated with workers compensation injuries
  4. They feel comfortable with
  5. Is efficient and organised.

 

Getting assessed by the NTD

 

When an injured worker visits their NTD, they should request them to complete paper work detailing their name, address, employment, and a history of what happened concerning the injury.  Most surgeries have computer software that has relevant questions and forms to be completed by workers compensation patients.

 

The doctor should examine the injured worker and discuss the circumstances of their injury.  They should give them feedback about what is wrong and what further investigations or treatment they may need, as well as approximate times frames for recovery if the injury is relatively minor and straight forward.

 

The doctor may need to issue a medical certificate that considers if the injured worker is unfit to work for a given period or ideally is able to manage selected duties. Medications may be ordered or a referral made for treatment, for example physiotherapy with a sprain injury.

 

Making a claim

 

A copy of the workers compensation medical certificate must be given to the employer who must, within 3 days, pass it on to their workers compensation insurer, along with paperwork concerning lodgement of the new claim.  From the information provided, the insurer assesses the liability status, and whether they will support treatment.  Some treatments such as physiotherapy and the initial visit to the NTD do not need the approval of the insurer; however, ongoing treatment and expenses must be approved except in limited number of specific circumstances.

 

There are 3 types of claim status that can occur in NSW for example, following claims lodgement and they include:

Full liability - relatively rare when the insurer fully accepts liability for what has happened - most likely after a significant injury that was associated with an investigation by WorkCover

Provisional Liability - Liability is accepted for treatment and payment of wages, and treatment for a period of time until the claim and circumstances are fully investigated.  The claim may later be accepted in full or declined.

Reasonable Excuse- There are some circumstances where the costs of treatment and wages are not required to be paid because of “a reasonable excuse”.  Some examples of this may be a psychological injury claim where performance management issues over alleged poor performance or misconduct have been carried out by the employer and the employee has become distressed and reported a psychological injury.  Even though wages and treatments are not paid, the insurer is required to have the claim investigated and the workers medically or psychiatrically assessed independently   After all the evidence is collected and reviewed a decision is made about the future claim status as to whether the claim is accepted or declined.

 

The treatment team and the rehabilitation team

 

 

  •  The Treatment Team

 

After an injured workers has visited their doctor, he or she may order some tests to clarify the nature and extent of the health issue to determine a diagnosis and the most appropriate treatment plan.  He or she is also likely to refer the injured worker to a medical specialist or an allied health professional such as a chiropractor, physiotherapist or psychologist, depending on the nature and severity of the work related injury or illness.

These allied health professional are part of the injured workers “treatment team”. Their focus is on providing treatment and will allow the injured persons body and/or mind to heal as quickly as possible so they can return to their pre-injury job.  It is worth pointing out that about 85% of all work place injuries resolve within 2 weeks, the implications being that the majority of claimants will have limited need for referrals to specialists or allied health professionals, and when and if they do, the number of treatments they require will be minimal.

For the remaining 15% or so of work injuries the situation surrounding the injury or treatment is likely to be more complex. The injury might be more severe or complex - i.e. incorporating both physical and psychological injuries.  There may be problems with accessing diagnostic procedures - e.g. there may be lack of approval for services by the insurer or, suitable duties may not be offered or available at the pre-injury workplace. Other personal or health issues may intrude on the progress of treatment and rehabilitation of the work related injury.

It is the NTD’s job to monitor the progress of the referral and treatments and make adjustments to the medical certificate and treatment plan as requirements.

 

  • The rehabilitation team

 

Where injuries are more serious or the issues associated with the injury are complex, an insurer or employer may appoint a workplace rehabilitation provider (WRP).  All WRP’s must be accredited by Workcover NSW.  

Initially the employer may choose a workplace rehabilitation provider - the vast majority of rehabilitation provider referrals are initiated by the insurer with who the employer’s policy is taken out.  The provider appointed tends to be the employers  “preferred providers” in that they usually have a contract concerning their fee structure and way of operating that is complimentary to insurer’s business model and approach to injury management.  The majority of these rehabilitation providers are medium to large in size and have offices in range of locations.

The doctor, worker, union, insurer or employer can initiate a rehabilitation referral. Injured workers CAN request on a provider of their choosing.  At least 50% of the accredited rehabilitation providers are not insurer preferred providers. Their work is generated by reputation with unions, allied health, doctors, employers, and / or through reputation they have developed concerning the quality of services they have provided to injured workers in the past.

The workplace rehabilitation team consists of a case manager who oversees all aspects of the case.  A good workplace rehabilitation service provider will ensure a comprehensive initial assessment is undertaken.  This assessment will be holistic in that it will be used to identify all the relevant factors and issues of injury management that need to be considered to ensure a good response to medical intervention and an increased capacity to return to work. 

 

The initial assessment may identify the need for other services to help facilitate independence, treatment responsiveness or to increase capacity to undertake preinjury work duties.  Some of the assessments that may need to be undertaken include: 

 

A workplace assessment - This assessment is usually performed by an occupational therapist that will visit a worksite and assess a range of aspects of the work environment with the view of facilitating an incident free return to work.  This may involve changing the layout of a desk or work station, or providing other types of aids that assist the injured worker carry out their work role. 

 

A functional Assessment -  This assessment is carried out by an Occupational Therapist, physiotherapist or exercise physiologist explores the physical capacities a worker has in realtion to specific activities they may need to carry out in their everyday life or in their work place.  It may include assessment of tolerances for repeated lifting or bending when that is a requirement of the injured worker’s job. 

 

Vocational assessment - A vocational assessment explores a workers potential job options in context of their education levels, qualifications, acquired work skills and their transferable skills after their injury limitations and work skills affected by their injury are taken in to consideration.  Consideration is also given to the labour market, training required to become competitively employable, and time frames and costs.  A good vocational  assessment will carried out on more than one day and will involve the workers input and job preferences.

 

Ongoing Case management - Only workers who are certified fit for suitable duties by their NTD can have ongoing workplace rehabilitation support.   An experienced and skilled case manager will have a natural empathy for the injured worker’s situation and for the other stakeholders and be inspirational and motivational. They will communicate and engage with all stakeholders and help to coordinate services to maximise the prospects for a safe and durable plan for the injured worker to return to “suitable employment” whether it is with the same employer or in a different job with a different employer.

 

 

The role of the insurer / agent

The insurers, now called “Agents” by Workcover NSW play key roles in the management of the Workers compensation system.  They hold the purse strings to medical and paramedical assessments and treatments, to rehabilitation access and the ability of the worker to access a weekly wage when they are injured. Over the last 5 or so years agents have been given increasing freedom in the way they manage claims to fit within their approved Workcover business model,  providing they adhere to the legislation and Workcover Guidelines concerning procedures, practices and timeframes..  Since the O’Farrell Government’s 2012 legislation  was passed their power has increased further in that the assessments they undertake on injured workers, particularly work capacity assessments are harder to challenge successfully as many of the appeal mechanisms have been watered down.

 

Some of the roles of the agents / insurers are summarised below:

 

  1. Collect premiums from employers for their compulsory  Workcover policies.
  2. Calculate and adjust premiums according  to industry, occupation, and  claims history
  3. Organise relevant assessments to determine liability
  4. Provided timely information to stakeholders over issues of liability and treatment changes 
  5. Develop a coordinated injury management plan with responsibilities outlined for treatment providers and other stakeholders
  6. Pay for “reasonably necessary” medical assessments and treatments
  7. Monitor the effectiveness of treatments  - through discussion with service providers and the organisation of “independent” assessments 
  8. Pay the injured worker a wage according to relevant legislation and make adjustments as require by legislation to accommodate changed or specific circumstances 
  9. Monitor compliance e of workers to their “obligations” in attending specialist appointments, treatments, job searching. 

 

Contacts with the Agent

 

Within a week of an injured worker lodging a claim with their employer, they should receive correspondence from the Agent.  The case manger assigned to the case may call to discuss the claim or some issue related to treatment - a claim number should also be assigned within this time frame.

It is important to understand that being assigned a claim number does not always mean that the claim has been accepted. It merely means a claim has been registered and a decision is to be made about status.  -  refer to the preceding sections on different type of claims status. In the letter the injured worker received from the agent giving them the claim number the letter may outline a management plan and some information about their responsibilities.  Some insurers may also (rarely) outline the injured workers rights about such things as the right to:

 

  1. Claim for travel to and from medical appointments and how to do so
  2. Claim for medicines and how to do so
  3. To receive support at home in the form of home help to do things such as mow the lawn, cleaning etc.(if your injury is substantial)
  4. Have modifications made and paid for such things as railings and showering aids or to help with food preparation and other things to help you maintain independence
  5. Choose treatment providers including the rehabilitation provider to assist you back to work

 

These issues are more likely to be relevant if the injury is substantial, and (several months down the track), they have not progressed in treatment, and residual injury symptoms are impacting on a range of activities of daily living.

In the first month the injured worker is likely to receive correspondence from the agent on several occasions - notifying of claim number, then the claim status and to receive an initial injury management plan. The case manager may call the injured worker to gain advice on a matter related to a treatment request, or certification issues by the doctor.

The approach and professiolism of “case mangers’ various greatly from agent to agent and between agents.  Some case managers are informative polite, helpful and empathetic.  Others may be ignorant, lacking knowledge and experience, prone to rudeness, or are, suspicious and generally unhelpful.  This will be discussed at some length in the section Challenges in the Workers Compensation system

 

 

What the employer should be doing

 

In the first month post injury the employer should:

  • Detail the incident leading to the works compensation claim
  • Complete and lodge the paperwork related to the claim
  • Forward payment for wages passed on from the insurer to the injured immediately after they receive them
  • Provide suitable duties as per guidelines on the medial certificate
  • If the employer has difficulties providing suitable duties, or is unsure what they should be doing they should contact the insurer or WorkCover for advice.   

 

 

What  the injured worker is  supposed to be doing and not doing - their obligations

 

To receive and continue to receive workers compensation benefits and to have their treatment and rehabilitation expenses paid they need to:

 

  1. Attend appointments with their NTD as requested
  2. Ensure your medical certificate is always up to date and forwarded to relevant parties  -  particularly the agent who is paying them.
  3. Attend all referrals made by the NTD for assessments and treatment
  4. Give adequate notification of cancellation if they are unable to attend
  5. Advise the doctor or the agent of any change in circumstance -  i.e. injury status,  change of address
  6. Undertake medical assessments organised by the agent providing they are given reasonable notice and they are within a distance that they are able to travel in view of your injury
  7. Participate in rehabilitation program organised by the agent or the employer (although they can elect to change provider if they are not happy with the service of the employer or agent appointment provider

 

 

The role of WorkCover in the first month

 

If all parties do what they are supposed to do in the first month there shouldn’t be need for Workcover assistance. If there are problems in the following areas a call to their assistance line may be warranted and help up in getting things moving with your case

 

  1. The employer won’t lodge a claim
  2. The employer doesn’t appear to have a policy
  3. The injury was caused by a clear and significant occupational health and safety breach
  4. They receive no response from the agent about the claim within 10 days
  5. They are not advised of your claim status and they receive no wage payment after 2 weeks
  6. Treatment or investigations that the doctor says is reasonably necessary are ignored or refused
  7. The employer refuses to offer suitable duties consistent with the medical certificate.

 

 

  • See Common Problems and What to do about them

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