Workcover insurance companies will use various fraudulent activities, these include
- inaction by insurer which contributes to fraudulent claims (1)
- obtaining medico-legal reports (such as IMEs) who have a vested interest in providing reports that favour the insurer, or lack of duty of care in not presenting medical reports that favour the injured worker (2)
- companies are able to buy self insurer status as a commercial transaction without scrutiny of good health and safety performance (3)
- pressuring an injured worker to return to work before they are ready (3)
- self insurers making it difficult for injured workers to make claims (3)
- failure of workcover insurers to assist injured worker when employer does not report injury accurately (4)
- cancellation of payments without warning (5)
- doctor shopping and collusion between insurer and doctors they appoint (6)
- delays in processing claims and allowing required surgery (6)
- accepting documents not tabled before review for injured workers to see(6)
- withholding financial entitlements (6)
- use of standover tactics or interfering with witnesses for the claimant (6)
- used video evidence that was false including cases where video was of someone other than the claimant (6)
- inconsistencies in admitting liability but only paying partial compensation (6)
- failure to advise people of their rights, providing false or misleading information and providing conflicting advice depending on which officer deals with the claim that day (6)
- claiming that the staff officer who signed a form was unaware of what they approved (6)
- providing wrong and misleading evidence to judge (6)
- possible conflict of interest between the rehabilitation provider and the insurer (6)
- failure to explain claims process to injured worker and making claimant sign papers without understanding the content (6)
- not allowing time for claimant to get specialist reports (6)
- failure to pay for services promptly making some service providers reluctant to treat injured workers
- inaction by insurers and failing to return calls when claimant asked questions (6)
- telling employers who employ claimants that their premiums will rise and that they will be audited, or outsourcing to agencies owned by WorkCover employees (7)
What I often do…
At a time when injured workers are at their most vulnerable they are suddenly confronted with a complex, often bureaucratic, system with delays that they do not understand, and the inefficiencies and incompetence are often not perceived as fraud, but they are!
References
(1) Australian Industry Group, Submission No. 53, p. 10.
(2) Mr Stig Hellsing, Transcript of Evidence, 16 October 2002, pp. 44, 50.
(3) Australian Manufacturing Workers’ Union, Submission No. 35, p. 9; Dr Deborah Vallance, Australian manufacturing Workers’ Union, Transcript of Evidence, 26 November 2002, p. 375; Ms Gwyneth Regione, Australian Manufacturing Workers’ Union, Transcript of Evidence, 26 November 2002, p. 276.
(4) Ms Leah Palazzolo, Submission No. 8, p. 2
(5) Injuries Australia Ltd, Submission 27, p. 3.
(6) Injured Persons Action & Support Association, Submission No. 69, Appendix 1
(7) Mr Mark Moore-McQuillan, Submission No. 16, p. 2 and Transcript of Evidence, 21 November 2002, pp. 295, 300.
I love the way you handled it!
The fact is that there’s no requirement to speak to these morons. Ask them to cease contacting you by telephone and deal with them in writing only.
I’d like to see them squirm out of something that’s been put in writing.
As for fraudulent conduct, whenever the insurer or doctor engages in such activity it must be reported. Remember that the insurer will not find one of its own as engaging in such conduct. As such it must be reported to the approproate external party.
Remmeber also that WorkSafe & WorkCover will seek to avoid embarassment and as such may collude with the insurer to “settle things” with the complainant.
You must be tenacious in holding every person involved with your claim to account.
We all have good days and bad days, you have to get up on those bad days and know that you need to keep up the fight as it is in your own interests.
Good luck!
Thanks for your comment, greatly appreciated! Tell me, who should we (workcover victims) complain to in the first instance, when there is evidence of ‘fraud’ or cover-up etc?
BASIC MATTERS
These should be addressed to the General Manager of the insurer.
Remember though that the insurer will be reluctant to make a finding against one of their own. They are as thick as thieves and will collude with statements and whatever else so as to protect fellow team members.
Also, the insurer will not want to jeopardise its licence to offer workers compensation insurance and will thus seek to bury any matter. It may suggest to you that the matter was handled appropriately, or that too much time has passed and that this is no longer their focus, or even that the staff member has left. None of these things should preclude it from properly handling any valid complaint.
Remember that the insurer is likely required to handle all complaints in accordance with the Australian Standard for complaint handling in organisations.
Any complaint should ask the insurer to provide a copy of the complaint handling policy any matter was handled under. That policy should also detail escalation options and processes should the complainant remain dissatisfied.
MORE SERIOUS MATTERS
These should be referred to the workers compensation authority in your state.
Remember that if the authority does not handle a complaint properly, and in accordance with government policy, that a matter can be referred to the Ombudsman.
SERIOUS MATTERS
Evidence of fraud can also be handed over to the police – as has happened with the recent Thomson-Labor-Union-Prostitute scandal (both in NSW and in Victoria). However, I am of the impression that police seem very reluctant to get involved with white collar crime.
If a complaint to the police is appropriate, it should be referred to the top, to the Police Commissioner. He can then delegate as appropriate, but in the end he will be responsible for any decision to investigate (or not to investigate).
LOCAL MEDIA
Remember that these companies and authorities hate bad publicity. Local media may also be interested in accusations of fraud.
The authorities spend a lot of time tweeting about fraud by workers but we don’t see any tweets about fraud by insurers. It’s time to hold them to account!
Thank you for the very useful information – I must say that I have lodged quite a few complaints with the workcover insurance and never hear back from them! I have recently sent a 9 page complaint letter to WorkSafe and hope to hear from them soon.
When you make a complaint a holding reply should be issued immediately. That reply should acknowledge receipt of your complaint and inform you of applicable timeframes, who will be handling your complaint, how to contact that person and the applicable policy under which the complaint will be handled.
I would suggest that if you hear _nothing_ back from WorkSafe within a month that you refer any such matter to the Victorian Ombudsman.
I’d be doing that for all past non-response matters too!
It’s just a big game
And one we can’t really win because they have all the time, money and doctors to win one way or another.
The sooner the injuried get their head around it and realize we actully win when we don’t play this game and move on with our lives.
It’s the only way
I think we all want nothing but to move on with our lives, and close the chapter. But for those – like me- who are seriously injured and hence pretty disabled, we’re unfortunately stuck with workcover for ever, certainly for medical and like benefits (even if you can get a common law damages claim). This means that we have to beg on a almost daily basis for stuff we’re entitled to such as organising a taxi trip to medical appointment, getting an MRI, additional home help, whatever. It is that, very unpleasant, aspect that wears me down and which makes me so angry. Because nothing is easy, even if they have approved your “serious injury status” (more than 30% impairment), they will still try to deny you every little ‘benefit’ and make your live as miserable as possible.
You have really interesting blog, keep up posting such informative posts!