Insurer/ Agent Issues

Problem 

Suggested  strategies

Wages  not paid on time by agent 

• Make sure medical certificate is current and  forwarded, if there is a pattern of “ we didn’t get it” call the agent after  faxing to ensure they have received it
• If problem is persistent   -  i.e.  more than 3 times within a 3 month period consider making a verbal complaint  to a supervisor
• If this doesn’t resolve the issue contact Work  cover’s help line
• If further problems make formal written complaint to  WorkCover and Agent’s complaint service detailing what happen and when.

Wages  not paid by employer

• While the goal of RTW same employer remains, the wage  to the injured worker is usually paid through the employer. The employer pays  what they are required to pay, i.e. for the amount of hours the person is  certified to work - the agent pays the remained through the employer. When no  pay is received it is usually necessary to call the employer initially.  If the matter still isn’t resolved  satisfactorily call the agent.
• If the problems persists call Work cover’s help line  and/or speak to your solicitor
• Some rehabilitation providers can help with issues of  wages and entitlements

Wages  do not appear correct

• Discuss with agent and find out the basis of their  calculations
• If you have documentation to support what you claim  is correct forward a copy to agent
• Consider discussing with your solicit.

Expenses  for travel to medical appointments and or medication are not reimbursed by  insurer or there are extensive delays

• Initially call agent and your claims manager and check that they have been received and when they will be processed.
• If payment is not forth coming consider call WorkCover.

Insurer  ignores a request for a procedure or support service - e.g. home help,  treatment referral. 

• Make sure NTD has identified the service need on  medical certificate
• Make sure NTD has made specific referral for the  procedure or service
• Make sure agent has received and on what date
• Identify the Workcover guideline time frame agent is  required to make a response
• When that time has passed call agent and continue at  least weekly for 3 occasions.
• If there is still no response call Workcover's support  service.

A support a service or referral  refused by the agent

• Make sure the reasons are in writing
• Try and find out why - often the feedback is given to  the provider of the service if they make the request rather than the injured  worker.
• Attempt to get a copy of the document rejecting a  service -   Discuss with  service provider -  sometimes  agents want more information and the onus is on the provider to forward the  requested information

Agent  refers for an Independent Medical Assessment and the opinion is significantly  different re management of the injury from that of the NTD and other.

• Discuss  with NTD including implications.
• The NTD ultimately has responsible for managing your  injury and the agent can attempt to influence a course of treatment however  they cannot enforce it.
• If treatment does not appear to be progressing  however “independent assessments” are sometimes arranged which aim to  reassess the liability of the insurer of managing the injury and claim.  Sometimes the opinion on of the Independent assessor is that the injury has  now resolved, or is no longer work related is the basis of the agent  declining the claim. All treatment and wages are then terminated.
• Good communication between treating professionals and  the agent can reduces the chance that the agent will take this stance. Sometime  however actions are directed top down and there is very little an individual  claims officer can do.
• If a claim is declined it is fairly essential to get a  legal opinion of options

A Work  Capacity Assessment is carried out and the findings are inconsistent with  your injury experiences, feedback from your treatment team from your  perceived real work capacities and work experiences

• At this  point time there are no mechanisms in place to challenge work capacity  decisions except on procedural grounds – I.e. not enough time allowed to  attend assessment, assessment not submitted within time frames. 
• The issues involved with the newly  established  Work capacity  assessments ( including the right to legal representation to contest  assessment findings) are currently being worked out