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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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Home » Injured Workers » Injury Management- What is happening and When? » First Month After an Injury, Key Information to Know

First Month After and Injury, Key Information to Know

 

  • Reporting an Injury or Incident. Workplace injuries or Illnesses


If in the course of your work if you become injured (physically or psychologically, or contract an illness e.g from toxic fumes), you are usually entitled to have the costs of your medical treatment and rehabilitation reimbursed through the compulsory workers compensation policy that your employer is required to have. In fact, if your injury occurs at work The Federal Governments’ Medicare scheme or private health insurance may not cover you for treatment of the injury if you are entitled to workers compensation benefits.

 

  • Circumstances of injury  -


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 workers compensation claim may arise.  To minimise difficulties later on  accessing treatment and workers compensation benefits it is important to report incidents and injuries to your employer as soon as possible.  Employers are required to have policies for reporting incident and injuries.  They are also required to have  procedures in place to  prevent injuries (Workplace Health and Safety)  and a system of investigation  to avoid minimise risks of further accidents..

 

  • Making a claim


  • The first step in getting treatment or time off work to seek medical help for a workplace incident is the reporting of the incident to your employer. With traumatic incidents medical care and treatment is the priority.
  • The next step may be a visit to a doctor.  An employer may request a worker to see a doctor of their choice.  The doctor is consulted for ongoing follow up treatment, the nominated treatment doctor (NTD), is the decision of the injured work, not the employer or insurer.

 

  • 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 doctors do not like to undertake workers compensation work at all.  It is important when choosing a NTD to be aware of these issues and choose a doctor who:



  1. Is  experienced as a GP 
  2. Has experience with managing compensation claims
  3. Has empathy and understanding of the issues associated with workers compensation injuries
  4. You feel comfortable with
  5. Is efficient and organised

 

  • Getting assessed by your NTD


When you visit your NTD, they should request you complete paper work detailing your name, address, employment, and a history of what happened concerning your injury.  Most surgeries have computer software that has relevant questions and forms to be completed by workers compensation patients.

 

The doctor should examine you and discuss the circumstances of your injury.  They should give you feedback about what is wrong and what further investigations or treatment you may need, as well as approximate times frames for recovery if the injury is relatively minor an straight forward.

 

The doctor may need to issue a medical certificate that considers you are unfit to work for a given period or are able to work but doing specific  suitable duties. Medications may be ordered or a referral made for treatment, for example physiotherapy with a sprain injury.

 

  • Making a claim

 

A copy of the workers compensation medical certificate must be given to your employer who must, within 3 days (in NSW), 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 a limited number of specific circumstances.

 

There are 3 types of claim status in NSW 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  independently medically or psychiatrically assessed. After all the evidence is collected and reviewed a decision is made about the future claim status -  i.e.  whether the claim is accepted or declined.

 

  • The treatment team and the rehabilitation team

 

The Treatment Team


After you have visited your doctor, he or she may order some tests to clarify the nature and extent of your health issue to determine a diagnosis and the appropriate treatment plan.  He or she is also likely to refer you 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 your “treatment team”. Their focus is on providing treatment that will allow your body or mind to heal as quickly as possible so you can return to your 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 requirements.



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 who 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. Injured  workers CAN request a provider of their choosing.  At least 50% of the accredited rehabilitation providers are not insurer preferred providers. Their work is generated by reputations they have developed  with unions, allied health, doctors and employers. Their  reputation has usually developed because of  the quality of services they have provided to injured workers and employers 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. It 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 this 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  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 as 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 a key role 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:

 

  1. Collect premiums from employers for their compulsory  Workcover policies
  2. Calculate and adjust premiums according  to industry, occupation, and  claims history
  3. Organise relevant assessments to determine liability
  4. Provided timely information to stakeholders over issues of liability and treatment changes 
  5. Develop a coordinated injury management plan with responsibilities outlined for treatment providers and other stakeholders
  6. Pay for “reasonably necessary” medical assessments and treatments
  7. Monitor the effectiveness of treatments  -  through discussion with service providers and the organisation of “independent” assessments 
  8. Pay the injured worker a wage according to relevant legislation  and make adjustments as require by legislation to accommodate changed or specific circumstances
  9. Monitor compliance  of workers to their “obligations” in attending specialist appointments, treatments, and job searching



It is important to understand that being assigned a claim number does not mean that your claim has been accepted. It merely means a claim has been registered and a decision is to be made about status.  In the letter you receive from the agent giving you the claim number the letter may outline a management plan and some information about your responsibilities.  Some insurers may also (rarely) outline your rights about such things as:

 

  1. Your right to claim for travel to and from medical appointments and how to do so
  2. Your right to claim for medicines and how to do so
  3. Your right (if your injury is substantial) to receive support at home in the form of home help to do things such as mow the lawn, cleaning etc.
  4. Your right 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 you maintain independence
  5. Your right to choose treatment providers including the rehabilitation provider to assist you back to work

 

These issues are more likely to be relevant if your injury is substantial, and (several months down the track) you have not progressed in your treatment and residual injury symptoms are impacting on a range of activities of daily living.

 

In the first month you are likely to receive correspondence from the agent on several occasions - firstly notifying you of your claim number, then your claim status and an then an initial injury management plan. The case manger may call you to advice on a matter related to a treatment request, or certification issues by your doctor.

 

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.

 

  • What your employer should be doing


In the first month post injury your employer should:

 

  • Detail the incident leading to your works compensation claim
  • Complete and lodge the paperwork related to your claim
  • Forward payment for wages passed on from the insurer to you immediately after they receive them
  • Provide suitable duties as per guidelines on the medical certificate
  • If the employer has difficulties providing suitable duties, or is unsure what they should be doing they should contact the insurer or WorkCover for advice

 

  • What you are suppose to be doing and not doing -  your obligations

 

To receive and continue to receive workers compensation benefits and have your treatment and rehabilitation expenses paid for you need to:

 

  1. Attend appointments with your NTD as requested
  2. Ensure your medical certificate is always up to date and forwarded to relevant parties  -  particularly the agent who is paying you
  3. Attend all referrals made by your NTD for assessments and treatment
  4. Give adequate notification of cancellation if you are unable to attend
  5. Advise your doctor or the agent of any change in circumstance -  i.e. injury status,  change of address
  6. Undertake medical assessments organised by the agent providing you are given reasonable notice and they are within a distance that you are able to travel (in context of any injury restrictions)
  7. Participate in any rehabilitation programs that are  organised by the agent or your employer (although you can elect to change rehabilitation service  provider if you are not happy with the service of your  employer or agent's preferred providerto one of your choice.

 

  • 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 call to their assistance line may be warranted, to assist in getting things moving with your case:


  1. Your employer won’t lodge a claim
  2. Your employer doesn’t appear to have a policy
  3. Your injury was caused by a clear and significantoccupational health and safety breach
  4. You receive no response from the agent about your claim within 10 days
  5. You are not advised of your claim status and you receive no wage payments after 2 weeks
  6. Treatment or investigations that your doctor says is reasonably necessary are ignored or refused.
  7. Your employer refuses to offer suitable duties consistent with your medical certificate

 

Workcover NSW  Claims assistance line

Phone 13 10 50

email contact@workcover.nsw.gov.au



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