The First Month After Injury
- Reporting
an Injury or Incident. Workplace Injuries or Illnesses
If in the course
of their work an employee becomes injured (physically or psychologically, or
contracts an illness (e.g from toxic fumes), they are entitled to have the
costs of their medical treatment and rehabilitation reimbursed through their employer's compulsory worker’s compensation policy. In fact, if the injury occurs at work The
Federal Government's Medicare scheme or private health insurance may not cover treatment of the injury if they are entitled to workers compensation benefits.
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 worker's compensation claim may arise. To minimise difficulties down the track with accessing
treatment and workers compensation benefits it is important that incidents and
injuries are reported to the employer as soon as possible. Employers
are required to have procedures for reporting incident and injuries as well as policies and procedures in place to prevent injuries
(Workplace Health and Safety).
When an injured worker sustains an injury they may require treatment and time off work to seek medical help. With traumatic incidents medical care
and treatment is a priority, and training and procedures should have been
implemented to all staff in what to do when a more serious injury occurs. The next step for the
injured worker is a visit to a doctor.
An employer may request a worker to see a doctor of their choice,
however the worker has the right
to consult a doctor of their choice and nominate him or her to be their
Nominated Treating Doctor (NTD) for ongoing management of the medical aspects
of their injury.
- 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 chooses a NTD they are aware of these issues and chooses a doctor who:
- Is experienced as a GP generally
- Has experience with managing compensation claims
- Has empathy and understanding of the issues associated
with workers compensation injuries
- The injured worker feels comfortable with
- Is efficient and organised.
- Being
assessed by the NTD
When the injured worker visits their NTD, they are likely to be asked to complete paper
work detailing their name, address, employment, and a history of what happened
concerning their injury. Most
surgeries have computer software that has relevant questions and forms to be
completed by workers compensation patients.
The doctor should examine the worker and discuss the circumstances
of their injury. They should
give feedback about what is wrong and what further investigations or treatment are
likely to be needed, as well as approximate times frames for recovery if the
injury is relatively minor or straight forward.
The doctor may need to issue a medical certificate
that states the worker is unfit to work for a given period or only for selected
duties. Medications may be ordered or a referral made for treatment, for
example physiotherapy with a sprain injury.
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
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 - whether the claim is
accepted or declined.
- The
treatment team and the rehabilitation team
The
Treatment Team
After the worker has visited their NTD, tests may be
ordered to clarify the nature and extent of injury or health to determine a
diagnosis and the appropriate treatment plan. The NTD is also likely to refer the 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 injured
worker’s “treatment team”. Their focus is on providing treatment that will
allow the injured person’s body or mind to heal as quickly as possible so that
can return to Hteir 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 your 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 required.
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 whom the employer’s policy is taken out. The providers appointed tend to be
their “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, however approval must be given by the insurer. Injured workers CAN request a provider of their choice as opposed to
the one allocated by their employer or insurer.. 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 who explores
the physical capacities a worker has in relation 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:
- Collect premiums from employers for their compulsory Workcover policies
-
Calculate and adjust premiums according to industry, occupation, and claims history
-
Organise relevant assessments to determine liability
-
Provided timely information to stakeholders over
issues of liability and treatment changes
-
Develop a coordinated injury management plan with
responsibilities outlined for treatment providers and other stakeholders
- Pay for “reasonably necessary” medical assessments and
treatments
-
Monitor the effectiveness of treatments -
through discussion with service providers and the organisation of
“independent” assessments
-
Pay the injured worker a wage according to relevant
legislation and make adjustments
as require by legislation to accommodate changed or specific circumstances
-
Monitor compliance of workers to their “obligations”
in attending specialist appointments, treatments, job searching.
Contact
with the Agent
Within
3 days of lodging a claim with the employer's insurer the employer and injured employee should receive a response. The case manager assigned to the case
may call to discuss the claim, and will also call the injured worker,
particularly if there is 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 mean
that a workers claim has been accepted. It merely means a claim has been
registered and a decision is to be made about status. As a treatment provider the assignment of a claim is no guarantee that you, as a treatment provider will be paid, even in situations where formal approval is not required - e.g.. a "reasonable excuse" claim - refer to the
preceding sections on different type of claims status. In the letter the
injured worker and employer receives from the agent, as well as a claim number, the
letter may outline a management plan and information about responsibilities of the various stakeholders involved in the calim - i.e treating doctors, employer worker and agent. It may also include information about workers entitlements to reimbursments for example they have a right to claim:
-
Travel to and from medical appointments
and how to do so
-
Medicines and how to do so
-
To receive
support at home (if their injury is substantial)in the form of home help to do things such as mow the lawn,
cleaning etc.
-
To have modifications made and paid for
such things as railings and showering aids or to help with food preparation and
other things to help maintain independence
-
To choose treatment providers including
the rehabilitation provider to assist them back to work
These
issues are more likely to be relevant if the worker’s injury is substantial,
and (several months down the track) the worker has not progressed in their treatment
and residual injury symptoms are impacting on a range of activities of daily
living.
In
the first month both the employer
and worker are likely to receive correspondence from the agent on several occasions. The case manager may call the employer and the worker to advise on matters related to treatment requests, or certification
issues by the workers NTD.
The
approach and professionalism of “case managers’ 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"
Roles of Employers, Injured Workers and Treatment Providers in the First month After Injury
What the employer should be doing
In
the first month post injury the employer should:
- Detail the incident
leading to the workers
compensation claim
- Complete and lodge the
paperwork related to the claim
- Forward payment for
wages passed on from the insurer to the worker immediately after they receive
them
- Provide suitable duties
as per guidelines on the medial certificate.
- If you have difficulties
providing suitable duties, or are unsure what you should be doing, contact your
agent or WorkCover for advice.
What the worker is suppose to be doing
To
receive and continue to receive workers compensation benefits and have treatment
and rehabilitation expenses paid for the worker needs to:
-
Attend appointments with their NTD as requested
-
Ensure your medical certificate is always up to date
and forwarded to relevant parties
- particularly the agent
who is paying them
-
Attend all referrals made by their NTD for assessments
and treatment
-
Give adequate notification of cancellation if they are
unable to attend
-
Advise their doctor or the agent of any change in
circumstance - i.e. injury
status, change of address
-
Undertake medical assessments organised by the agent
providing they are given reasonable notice and they are within a distance that can
be travelled to in view of their injury limitations
-
Participate in rehabilitation program organised by the
agent or you (although a worker can elect to change providers if you are not
happy with the service of the rehabilitation provider you or the agent arranges
What the Treatment Providers should be doing
Unless the worker's injury is serious and requiring immediate hospitalisation the majority of medical intervention in the first month will involve the NTD. He or she will need to consider:
-
Otaining a detailed injury history
-
Identifying any significant red flags requiring immediate intervention
-
Establishing the claims status
-
Refering for further investigation
-
Refering to other specialsits or medical staff for further assessment or treatment
For other treatment providers the onus will be on
-
Establishing claim details
-
Establishing the claim status
-
Arranging an initial assessment consultation,
-
Giving initial feedback to the injured woker and referring NTD about the injury status and treatment needs
-
Developing an injury management plan
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
worker may need to call to their assistance line to help getting things moving calls are often made:
-
If the employer won’t lodge a claim
-
If the employer doesn't appear to have a policy
-
The injury was caused by a clear and significant
occupational health and safety breach
-
There was no response from the agent about the workers
claim within 10 days
-
The worker wasn't advised of their claim status and
doesn’t receive wage payment after 2 weeks
-
Treatment or investigations that the worker’s NTD says
is reasonably necessary are ignored or refused
-
The employer refuses to offer suitable duties
consistent with the worker’s medical certificate.