We have put together information to keep injured or ill persons informed of what to expect.
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All employers play a crucial role in the prevention and management of workplace injuries.
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Information for Psychologists, Occupational Therapists, Nurses, Exercise Physiologists and Doctors.
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Other key stakeholders are also encouraged to provide Information and comments about issues of relevance .
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Insurer/ Agent Issues

The insurers / agents are the managers, gate keep and bean counters of the NSW Workers Compensation system.  Since the 2012 legislation was passed they have been give increased powers and responsibility for managing the claims and in ensuring costs are controlled, particularly in ways that may have adverse consequences for employers and their profitability.
For injured workers, nominated treating doctors, treatment providers and rehabilitation providers the  relationship they have with the claims officer managing a particular injured workers claim can and does make an enormous difference to how quickly decisions are made, referrals and treatments approved and payments made.  Although there is legislation in place and guidelines set by WorkCover about what can and cannot be done and when, the level of efficiency, attitude and professionalism of agent staff varies greatly between and within agencies.
 
The majority of complaints made to Work cover by injured workers and treatment provider relates to agent related problems.  Some of these are appropriate and relevant to Work cover, some are related to legal issues that need to address through legal representation by a lawyer.  As result of the changes to the Workers Compensation Act in 2012 there are some decisions that can no longer be appealed by an injured worker. i.e. aspects of work capacity decisions (see changes to the act), and there are some areas where funding is no longer available for legal representation.
 
At the one to 3 month stage of a claim the most typical challenges from agents are in the following areas:
  1.   Full liability
  2.   Provisional Liability
  3.   Reasonable excuse
  4.   Declined claim
Potential problems with the status are overviewed below.
 
 
Full liability - With full accepted liability a claim is accepted in full within the guidelines of legislation - wages should be payed, travel and medically related expenses refunded and “reasonable and necessary” treatments provided.  Problems most frequently reported by injured workers relate to delays or denial of treatment s or specialist referrals and late or non payment of wages and expenses.  Injured workers may need to call the agent and then Workcover to address these issues
 
Provisional Liability -The rights and obligations of workers with a provisional liability claim are the same as those with a full claim, however their claim is usually under investigation as to whether the injury - physical or psychological is work related.  The investigation is organised by the agent who recruits medical or ara medical specialist called “independent specialists” and other agencies who are contracted to perform a specific role - i.e. private investigators or factual investigators. Occasionally an agent may request a report from a NTD, treatment provider or specialist the worker has been referred to by their NTD; however the agent is not obliged to do so. 
If the agent makes a decision that the claim is not work related they must provide a reason consistent with the act that supports their decision.  At this point a worker may need to consult a lawyer whether and how to appeal the decision.
If you as the employer have evidence that the worker’s injuries are not work related, and / or  they occurred as a result of a reasonable action taken by you i.e. a worker lodges a claim after performance reviews  you should contact the agent and advise of your concerns. When the agent sends an investigator to explore the issues leading to the claim from both sides, you should have clearly thought out your arguments and concerns.  Any evidence you have in writing or can be backed up by independent witnesses should be provided to the investigator. This will help to get a decision over liability made in your favour, which will result in the claim being declined and your premiums not being affected.
In the medium to longer term you will need to consider how will manage and support the injured worker even if he or she doesn’t have an ongoing w/c claim. You are still committed to providing a safe workplace, anti-bullying legislation and are potentially bound by Commonwealth laws concerning unfair dismissal. It maybe help to contact your employers or professional association, and, or seek legal advice.
 
Reasonable Excuse - An agent may make a decision after a claim is lodged that they will not pay any benefits or treatment expenses until after the claim has been investigated and the workers reported injury has been assessed.  This usually occurs when the there is evidence reported that the claim is not work related - i.e. the injury or illness was pre-existing or did not happen at work, or that the reported injury (particularly stress injuries) occurred as result of reasonable action by the employer – i.e. the worker was reprimanded for constantly being late, underperforming or stealing.
The Agent will apply the same procedures and be under the same time frames for a decision to be reached as with provisional liability.  This may mean that the injured worker receives no entitlements or treatments expenses for a period of 3 months.  If liability is accepted they will be back paid.   Workers can apply for Centrelink benefits in the meantime, but these will have to be back paid if the claim is accepted.  Injured Workers are advised to contact a lawyer at this stage for advice; however no action can be taken in terms of an appeal until a decision has been reached. If the agent takes longer than those of the guidelines- a call to Workcover may help in decision being made with the time frame guidelines.
For you as the employer see Provisional Liability above for suggested ways of managing.
 
Declined Claim - A decision is made in writing with reasons according the Workers Compensation Act outlining why the claim is declined.  A worker may need to consult a lawyer whether and how to appeal the decision.

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