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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 keepers and bean counters of the NSW Workers Compensation system. Since the  2012 legislation was passed they have been given increased powers and responsibility for managing the claims and in ensuring costs are controlled.

 

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 NSW WorkCover about what can and cannot be done and when, the level of efficiency, attitude and professionalism of agency staff varies greatly. 

 

The majority of complaints made to WorkCover by injured workers and treatment providers relates to Agent related problems. Some of these are appropriate and relevant to WorkCover, some are related to legal issues that need to be addressed through legal representation by a lawyer. Since the changes to  the Workers Compensation Act were passed  in 2012 there are some agent decisions that can no longer be appealed by an injured worker. These include  Work Capacity decisions (see changes to the Act), and  funding  for legal representation.

 

At the one to 3 month stage of a claim the most typical challenges from agents are in the following areas

Liability – As mentioned previously the 4 potential claims status are:

I. Full liability

II. Provisional Liability

III. Reasonable excuse

IV. Declined claim

Potential problems with the status are overviewed below.

 

Full liability - With fully liability a claim is accepted  within the guidelines of legislation. Wages should be paid, 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 or specialist referrals and late or non payment of wages and expenses. Calls to the Agent and then WorkCover is the best way to get advise on how to deal with related issues.

 

Provisional Liability -The rights and obligations of injured workers with a provisional liability, are the same as those with a full claim, however their claim is usually under investigation to determine whether there is a injury, physical and/or psychological,and if it is work related. The investigation is organised by the Agent who recruits medical or para medical specialist's called “independent specialists” Often an investigator is also contracted to investigate the circumstances leading to the claim.  Occasionally an agent may request a report from the NTD, treatment providers or the specialists 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.

 

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 worker's reported injury has been assessed. This usually occurs when the there is evidence that the claim may not be work related. The injury or illness may have been 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. Examples are when 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 a decision being made, with the required  time frames.

 

Declined Claim - A decision is made in writing outlining why the claim is declined  according to the Workers Compensation Act . A worker may need to consult a lawyer about whether to, and how to appeal the decision.

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