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Home » Injured Workers » Common Problems with Injury Management » Insurer/Agent Related Challenges

Insurer/Agent Related Challenges

  

The Agent, as the manager of each workers compensation claim is required to assess, decide on and evaluate the progress of each and every claim.  With as many stakeholders involved in even the simplest claim it is inevitable that there will be differences in opinion on a range of issues including treatments, rehabilitation, and timeframes, and needs are all regulated by legislation and associated WorkCover guidelines.  There are many examples  where problems can occur that will affect workers and their access to treatments. Some of the most common and possible strategies to address the issues are outlined

 

In the first Month

 

1) Non Response to Claim Application

 

What WorkCover has to Say

 

If the insurer does not respond to a new claim or a request for a specific benefit under Part 3, Divisions 2, 3 and 5 of the 1987 Act within 21 days, the worker can seek assistance from WorkCover’s Claims Assistance Service (CAS) on 13 10 50 or their union. CAS will issue the worker with a CAS reference number upon initial contact and then contact the insurer to facilitate a response. CAS will send a letter to the worker within 7 days of the request advising either:

• The insurer’s response (i.e. the action the insurer has taken or will take); or

• That there is still no response.

 

Once the 7 days has elapsed, the worker may lodge a dispute with the Workers Compensation Commission (WCC) quoting the CAS reference number and attaching the CAS letter. For the purpose of relying on the CAS reference number or letter to commence proceedings in the WCC, the CAS inquiry must be made no earlier than 7 days before the time limit for determining the claim has expired. The worker or their representative may also need to refer to the WorkCover Work Capacity Guidelines regarding payment of weekly payments

 

 

 

2) Ongoing Issues

 

Travelling Expenses not Paid

 

“If the worker has paid for reasonably necessary medical treatment, the insurer is to reimburse the worker within 7 days after the worker requests payment. If the worker has paid for travelling expenses to receive medical treatment or to attend a medical appointment that the insurer has arranged, the insurer is to reimburse the worker within 7 days after the worker requests payment. “

 

 Delays in Approval For Treatment or Service

 

Slow responses to treatment and rehabilitation service requests can occur, for specialist’s referrals and for investigative procedures. This is  the area where most complaints are made to WorkCover’s Claims Assistance Service.

 

It is important for Injured Workers and treatment providers to know that not all services require Agent approval providing there is a valid claim.  It is worth commenting; however,  that even when a valid complaint is lodged with the Agent and/or with WorkCover the vigorousness that the matter is pursued, followed up and dealt with, will determine how much attention and priority is given to the matter and what the consequences will be, if there is breach.  We are interested in hearing about injured workers and treatment providers experiences of dealing with Agents and Workcover on matters of treatment approvals.

 

 

OTHER COMMON CHALLENGES AFFECTING INJURED WORKERS

 

Problem 

Suggested strategies

Wages not paid on time by agent 

  • Make sure medical certificate is current and forwarded from the medical centre straight after the consultation.  If there is a pattern of “ we didn’t receivet it” call the Agent after faxing to ensure they have received the paperwork. Scanning/emailing can also be effective
  • If problems are 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 WorkCover’s help line
  • If further problems occur make formal written complaint to WorkCover and Agent’s complaint service detailing what happened and when. Keep detailed notes.

Wages not paid by employer

  • While the goal of RTW same employer remains, the wage to the injured worker is usually paid by the employer. The employer pays what they are required to pay, i.e. for the amount of hours the person is certified to work and the Agent reimburses the remaining  make up pay back to 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 WorkCover’s help line and/or speak to your solicitor
  • Some rehabilitation provider can help with issues of wages issues and entitlements

Wages do not appear correct

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

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

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

 Had 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 the service provider -  sometimes agents want more information and the onus is on the provider to forward the requested information
  • If no results then advise a solicitor and ask for help

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

  • Discuss with the NTD including implications.
  • The NTD ultimately has responsibility 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 “independent assessments” are sometimes arranged which aim to reassess the liability of the insurer for  managing the injury and claim. Sometimes the opinion 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. Sometimes;  however, actions are directed top down and there is very little an individual claims officer can do.
  • If a claim is declined it is sadly essential to get a legal opinion of your appeal 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

Claim is Declined

  • Make sure you receive written documentation outlining the reasons why and the appeal mechanism
  • Contact your solicitor or engage a WorkCover registered solicitor. 
  • See our Guidelines for Choosing a solicitor

 

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