Yesterday, aworkcovervictimsdiary.com received an email from a genuinely and severely injured worker who has had her medical expenses suddenly terminated by her workcover insurer, without a seemingly logical nor valid reason. She (and we) are wondering if there are any other injured workers out there who have had their medical expenses suddenly terminated and what steps they have taken to (successfully or not) address this outrageous termination.
Workcover termination of payments: when insurer suddenly terminates medical expenses
Injured workers’ email, published with permission from the injured worker (name and identifying bits removed to protect the injured worker)
I don’t quite understand and am trying to get some feedback from my WorkSafe agent (but we all know how that’s going to be).
Basically my accident was in [month] 2007, my medical panel opinion of ‘chronic pain disorder’ came in [month] 2009.
My medicals (acupuncture, physio, massage, neuro appointments, doctor appointments, scans, cortison injections etc) were covered until [month] 2011 and then I got the ‘based on your IME’s‘ termination letter. I asked for a reason and all I get is: ‘based on your 2009 medical panel opinion we don’t need to pay for your treatments, your soft tissue injury has healed‘.
So why had my insurer covered these treatments for almost 2 years post medical panel??? IME’s are the same as prior, never changed.
Stay tuned, I’ll try WorkSafe and then the Minister and we’ll see what happens. Last time I tried the minister I got ‘you are a complex case’ and that my issue was at conciliation which was enough of a reason to excuse our Minister from dealing with my complaint.
Let’s see what appalling discoveries I’ll endure this time.
And I have tried the Ombudsman’s service but they are unable to deal with Workers Compensation issues.
My only avenues seem to be WorkSafe or going to court.
Workcover termination of payments – medical expenses/treatment
A worker injured in compensable circumstances, whether or not the injury results in time off work, is entitled to payment or reimbursement of reasonable medical and other related expenses. The types of such expenses covered by the Act are set out in section 99 and cover such items as medical, hospital, ambulance, chemist, nursing and travelling expenses, artificial medical aids, as well as treatment by registered chiropractors and osteopaths. Other claims can include personal household and occupational rehabilitation expenses such as home help, gardening, and car and home modifications.
According to the online Law Handbook,the Act states that the expenses must be “reasonable”; that is, they must be reasonable as to the amount of expense, and to the necessity and frequency of treatment.
The liability for payment continues while the injured worker suffers from the effects of the injury, whether there is a return to work or not.
In the above case however, the injured worker is still receiving weekly payments. So obviously something doesn’t add up here. She is also past the 130 weeks. She is also still incapacitated and unable to return to work. She has a spinal cord implant to help control the pain and receives regular nerve blocks to further help with her debilitating pain.
Her main issue is that the medical panel stated that she suffered “a soft tissue injury that healed” and now she, unfortunately, suffers from a true chronic pain disorder as a result of that injury.
It appears that the “chonic pain disorder” may be the issue here, given that many doctors, so called independent medical examiners and even medical panel doctors (which are the same really, they are IME’s which rotate!) “see” chronic pain as a “psychological condition” rather than a physical condition, even though psychiatric assessments may prove the opposite! Unfortunately one should also not forget that the Medical Panel still uses the 20 year old (and most outdated) AMA guide 4th Edition (banned in countries such as USA and Europe!) to rate our “impairment assessments”. This AMA guide does not even acknowledge “chronic pain” (no box to tick). In cases where overt nerve damage (as in a severed nerve for example) may not be visible (as is often the case) severe chronic pain conditions are literally “dismissed” and , hence, the “system” does not recognise it! How convenient, not!
WorkCover has terminated my medical treatment, what should I do?
The most common reasons for a rejection or termination of medical expenses (as listed in our top FAQ based on information we gathered from our top law firm) are as follows:
- WorkCover medical advisers have indicated to WorkCover that the treatment is unnecessary.
- WorkCover considers the treatment is no longer effective or can be replaced by self managed home exercises.
- Weekly payments have ceased more than 52 weeks.
If WorkCover advise you that they intend to terminate your medical treatment expenses, you should refer the dispute to the Accident Compensation Conciliation Service for resolution of the dispute. And this is the only thing we have been able to suggest to this unfortunate workcover victim.
We also happen to know of a brilliant WorkCover Assist person, who came highly recommended by our Shine Lawyers. This guy, folks, KICKS BUTT and we would be happy to pass on his details should anyone of you need a butt kicker at Conciliation in Victoria.