WorkCover terminates payments – conciliation or medical panel?

We received an email from an injured worker overnight stating that after he had been sent to an independent medical exam (IME), his workcover insurer called him and cancelled his payments and all expenses on the basis of the IME’s opinion that his injury was not work related. The injured worker’s sollicitor advised him that the next step would be conciliation but the injured worker wonders whether it would be better to go to the Medical Panel to dispute liability….

WorkCover terminates payments – conciliation or medical panel?

The injured worker’s story and question: his own words

Recently I had an IME.  Today I get called advising my workcover is getting cancelled payments & all expenses because it was the opinion of the IME that as I have not bee n at work for 6 months that it is now not an injury from work!!

I tore the tendons in both my arms my orthopaedic surgeon wants autologous blood injections & if no success then surgery.

Is it really the opinion of the medical world that if u sit on your butt for 6 months they magically mend & re grow ? because they don’t.

I don’t know what the best step for me is next my solicitor thinks my best bet is conciliation but I was told it would probably be easier to go to the medical board/panel.  I really have no idea. Friends tell me one thing my solicitor well his assistant as even tho I ring him only she rings back & my union tell me another thing!!

Please any information or advise or somewhere I can get another opinion from would be great I just want them to pay for my treatment & if still unsuccessful surgery but I also need to still be paid I can’t help support my family from thin air
To answer your question: your sollicitor is correct and you now need to lodge a dispute with the Accident Compensation Conciliation Service (ACCS). You have 60 days to do so. The conciliator may be able to resolve the dispute or decide to refer the matter to a Medical Panel or to issue you with a Genuine Certificate of Dispute allowing you to pursue the matter in a Court of law. We strongly advise you to also use the free service of WorkCover Assist for Conciliation.

If I do not agree with decisions made by my Insurance Agent, how are disputes with WorkCover resolved?

When you sustain an injury at work, you can make a workcover claim. The workcover insurance company of your employer (e.g Allianz, Xchanging, Gallagher-Bassett, CGU, QBE etc) is then (or shall I say SHOULD then) be responsible to pay for ALL your reasonable and necessary medical and related expenses, as well as your lost wages (if you can’t work).

However, more often than not the workcover insurer will refuse to accept your claim in the first instance, or will often refuse to pay for certain necessary and deemed reasonable medical and related expenses or weekly payments which you and your treating doctors believe you are entitled to.

The Accident Compensation Act (the law which covers work injury claims in Victoria) states that the first step in resolving the dispute is to go to conciliation at the Accident Compensation Conciliation Service (ACCS)

With  proper guidance most disputes with WorkCover should be resolved without a court hearing. As the injured worker’s sollicitor correctly stated, [almost] all disputes are initially referred to the Accident Compensation Conciliation Service, which will attempt to resolve a dispute in an informal manner.In the above case, the dispute will revolve around “liability” for the injury, that is: whether it is work related or whether work was a substantial contributing factor.

It is necessary to lodge an application for conciliation. You have 60 days to lodge a dispute form and ask for Conciliation.

Lawyers are usually not permitted to appear at most conciliation hearings sometimes they can if for example the matter is about liability of injury), but two excellent and free advocacy services are available to assist you.

Union Assist is an advocacy service for union members and WorkCover Assist is a formidable free service able to help all other employees. If you are unhappy with the outcome of conciliation, you are able to pursue your claim by court action. If the Conciliator is able to rule at the conciliation they will issue with a certificate of outcome.

If you are unhappy with the outcome of conciliation, you are able to pursue your claim by court, however court should be a last resort.

How many reports can I obtain from my doctors for conciliation?

As many as you see reasonable, to address your case. So, basically get as many supportive medical reports from your treating doctors (including Physio, Rehab, Psychologist etc) as you possibly can!

Can I seek for my dispute to go to a Medical Panel?

Referring a matter to the Medical Panel is one of the ways in which a dispute with WorkCover can be resolved. A matter can be referred to the Medical Panel by a Conciliator at the Accident Compensation Conciliation Service. (a matter can also be referred to the Panel by a court and by an impairment benefits Officer at the request of a claimant who is disputing their percentage permanent impairment rating.)

A conciliator will usually refer a matter to a Medical Panel if it is a ‘medical question‘ as defined by the WorkCover legislation. Where there is a major factual dispute, this issue may often not be referred to the Medical Panel as it is more difficult for the Panel to decide factual disputes.This is a complex issue. A decision of the Medical Panel is  binding on the parties and a court is generally required to follow its decision.

Can I appeal the decision of a Medical Panel?

The decision of the Medical Panel can only be appealed on very narrow grounds. It is only possible to appeal the decision if the Panel has made legal error. It is not possible to appeal the decision of a Panel solely on the basis that it came to the wrong conclusion.

Learn more

Hope this helps and good luck to you, mate – keep us posted!
Note: if you have a question about your workcover claim, please post it under “need help with your workcover claim

 

Shortlink: http://workcovervictimsdiary.com/?p=9411

 



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22 Responses to “WorkCover terminates payments – conciliation or medical panel?”

  1. I am currently off work and have been since August 6th 1012.  I suffered a severe nervous breakdown at work.  Initially we sort medical advice and had all the tests done to rule out any physical condition.  all tests proved negative.  It was then I realised with the help of neurologist that this was a nervous breakdown and it then started to make sense.  I have been seeing a psychologist and psychiatrist and am on two type of high dose medication.  Both concur it is a workplace PTSD.  I saw a psychiatrist for the insurance company and they agreed to pay workcover.  Then three months later, they cancelled it and am forcing me to go to conciliation   This has caused a major setback to my recovery as I now have financial stress on top of my previous condition.  It feels like ground hog day everyday as I can’t go out of the house except to the supermarket, my sons golf course and for a walk around the block without a member of my family.

    I applied for concilation over six weeks ago and there is such a back log I still don’t have a date.  The whole family is now under stress because we only have my husbands wage to cover all our bills.  I went from 80K per year to nothing.  All our credit cards are maxed and I feel bullied by the insurance company that said they don;t have to take all medical reports into consideration and they chose to go with their specialist and discount any of my doctors reports.

    I can’t work as I struggle to concentrate, do day to day tasks like even shower and am fearful of walking out my front door.

    Workcover has been taking my money my whole working life and when someone needs it and has a legitimate claim they force it to go to conciliation in the hope it all becomes too difficult.  No wonder the system has a back log.  Why do that to someone who is suffering from a stress related condition?

    We are desperate and if something doesn’t happen soon who knows we might have to sell everything we own.

    Tracy

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    • Hi Tracy

      Hang in there.  Ring the manager at ACCS to get your date set.  There is a back log because of the way insurers abuse the scheme.

      I worked for a firm, where I (and many before me) were bullied out of their jobs by one of the partners – a complete psychopath.  My experience is similar to yours in that it was accepted after an 6 week investigation, only to be terminated on a dodgy IME report 3 months later – see a pattern?  Wonder if it is the same insurer/same IME.  This clown said I had the injury – but of course referred to it as “adjustment disorder”, not PTSD like my treaters diagnosed.  The IMEs they use are semi-retired and/or outdated as far as latest medical research.  The IME said I was OK to go back to the bully employer – no mention of treatment or changes to workplace.  Insurer knew employer was hostile and wouldn’t ever let me back after lodging claim, since he also had stated this in writing, so insurer got the dodgy IME to write another report to state it was ok for me to go back to “any” employer – again no treatment suggestions, nothing.  Went to ACCS and then Medical Panel.  ACCS do not have power to make decisions – especially when it is a “medical dispute”, which is most of the time, so after Medical Panels disagreed with the dodgy IME and of course that was 5 months later on no income and I was worse, the insurer had to back pay – but no interest to cover my maxed out cards etc.  No interest because it was a “medical dispute”.  So basically this is why the insurers do what they do – nothing to lose and in my case they kept my payments in their bank account for 5 months and earned interest on that amount while I was paying interest on my cards trying to survive.  Oh, even though Medical Panels decision is binding, insurer waited the maximum time (2 weeks) to pay me before they would be penalised for delay, because in their words ” had to see if they were ok with the panels decision”.  They really think they are a law unto themselves.

      One thing I’ve learned is that it is not personal – insurers bully systematically and get away with it most of the time due to the weak/vague/unfair  legislation in place.  It is not about a safe sustainable return to work, for the insurer it is about getting injured workers off the payroll.

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      Corrupt System reigns May 17, 2013 at 7:33 pm
  2. Sorry for what you are going through Tracy, I too have been on this merry go round and after 16 months I am still trying to get payments. The lies and deceipt that employers, insurance companies etc, pull to get out of paying you is rediculous. And as for going to their IME dont get me started on the rubbish that happens there. Good luck.

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    • I just want to curl up in a ball and sleep for the rest of my life or better still die and put everyone out of their misery.  I wouldn’t be able to sleep for the rest of my life anyway as I only get four hours sleep of a night time due to the PTSD.  Seven months of sleep deprivation can’t help with my recovery.

      I thought that because I was honest and sought to see if there was a physical reason for my condition first, I would’t have any trouble.  What a naive little girl I am even though I am 47 I still try to see the good in people.  At first with PTSD you loose touch with reality or a least I did and was at my doctors saying my husband abused me.  I went totally loopy and it wasn’t till I had exhaused every avenue I could seeing three neurologists, going to three different hospitals, have MRI and CT scans, blood tests you name it, and then my boss coming to see me to tell me they were going to pay me, that I realised this was trauma, even though the doctors had said it was psychological from the first visit to hospital.  I just didn’t want to admit I had broken as I was always someone who picked myself up and dusted myself off and got on with things.  And then I went to see the insurance companies appointed independent psychiatrist who saw me for all of half an hour and didn’t wnat to know what had happened just the symptoms of what I had at the time.  He then approved of it only to turn around and say because I was on steriods and had a arachnoid cyst (which by the way tested negative to have caused the condition) they were cancelling my claim.

      Then the fun (sarcasm) started.

      Tracy

       

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      • I feel for you Tracy, the Workover is really hard on psychiatric injuries, they know how vulnerable injured workers are and they take every opportunity to bully us and give us financial stress. I was left without income and psychiatric treatment for ten months before my claim was forced into acceptance by Medical Panel decision. Still had to wait another month or two after that to get any money. The Claims Manager ordered an IME assessment and surveillance on me before she bothered to back pay me.

        Try not to get too shocked by the meanness of this system. Expect it and plan for it. Keep going forward with your treatment too as leaving psych injuries to fester makes them much much worse. Ten years later, I’m unemployable, still suffering ptsd and Major Depression, homeless, and fighting with the Insurers for retraining to help me return to work.

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      • hi there, reading your blog I was thinking – this is me!!.  I am on workcover for bullying and harassment, resulting in  major depression, panic disorder, agrophobia and some PTSD symptoms .  Xchanging decided to send me to a IME, after 12 months.  the IME report wasn’t to bad, stating my injury was from work place bullying and would require further phyciatric care for the rest of the year, and that I was unfit for any duties, so then they asked for a supplementary report, the report one month on states that I can return to work within one month on his seeing me!!!! WTF, so my weekly payment have been suspended, I was ordered to undertake Rehab and be involved with jobsearch, which of course I couldn’t do, so now I have been terminated, interesting that I have since seeing the IME been in a PHYC ward for sucide ideation and attempt.  How does this continue to happen to people.  Insurance company should not be dealing with injured workers as they are a ‘for profit’ organization and its clear they will not be concerned with a injured person, what the hell is this government doing.  I wrote to the minister and never received a reply.  I think they want me to die so they don’t have to pay.

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        • also still waiting for conciliation after 8 weeks and hearing nothing, no date, no money, no life!

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          • I have been and still go there sometimes….that awful feeling of not wanting to be here anymore and just tired of all the bullshit….I also understand that feeling that they want you to be dead so they dont have to pay you…I too attempted suicide after a Medical Assessment Tribunal decision that found I had a zero impairment…but by the grace of something I dont understand…I am still here…those bastards have taken everything from me…but the one thing I will never ever let them take is my birthday….stay strong….I just went through another disappointment in my case but this site has shown me….I am not alone….there is support here…and the greatest gift of all…is you can support others too…take care of yourselves….that is the most important thing of all xxx

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  3. @Tracy – so so sorry you too are experiencing the workcover system as it truly is. Many of us, physically injured workers are made mentally ill by the way we are routinely being treated by the insurer – their modus operandi being known as SSS or Stall, Starve, then “Settle”. I can only begin to imagine what it must be like when you suffer from a primary psychological injury.

    You may want to consider joining our private Forum, where you can seek more advice and support at this most difficult time.

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    workcovervictim March 19, 2013 at 1:53 pm
  4. So here’s my story.  I’ve gone past the 2nd entitlement period and was approved some 5 years ago by the Medical Panel for S.93CD payments.  This means I have partially gone back to work but WorkCover is to make up the difference between my current part-time income and my old full-time income.  Once a year the insurer sends me to one of their “doctors for hire” aka IME’s and each year they say no change in my ability to work.  Then earlier this year I see what amounts to the 5th IME since the Medical Panel decision and he says I am the fittest person he is ever seen and I can go back to work full-time immediately.  I get medical reports from my 2 doctors saying my work capacity is unchanged but of course the insurer terminated my payments.  So its back to Conciliation and probably the Medical Panel.

    Where the system really sucks here is that the insurer is at “no risk”.  Normally in a legal dispute if I sue a person, I risk losing the case it will usually cost me my legal fees PLUS their legal fees.  Could cost $100k or more depending on the case.  But in this system, there is NO risk to the insurer in trying to get a 2nd bite of the cherry at the Medical Panel even though they lost 5 years ago.

    So when my Conciliation conference comes up, the insurer will simply say they have an IME that I can do full-time work and I will say I cant, then the Conciliator will send it off to the Medical Panel.  So now the insurer gets their 2nd chance without any financial risk to themselves, to kick me off WorkCover.

    Of course 5 years ago had I lost at the Medical Panel, then that’s that.  No more second chances for me.  But for the insurer, they make me see one of their doctor’s for hire once a year and hope to get me before the Medical Panel as many times as they can because after all, they only have to win once.

    As for the IME’s, the old saying “he who pays the piper calls the tune” is exactly right.  If a doctor is being used by the insurer sides with the insurer 10% of the time but another doctor sides with the insurer 90% of the time, which doctor do you think the insurers will look to use in the future? Its all about money greasing the wheels at every stage.

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    About Money NOT People June 5, 2013 at 7:29 pm
  5. hope you guys can give me a bit of advice. ive been on workcover for 12 months as i have ptsd from being bullied by my asshole boss. 3 weeks ago i was sent to ime for updated assessment cause i think allianz want to cut my weekly payments off. then this week my claims manager tells me they want to send me to another ime for a ‘supplementary report’. has anyone had this happened to them? I dont get why im being sent back for another ime assessment only 3 weeks apart & why i would be sent to different ime for this supplementary report. also why not send me back to the same ime, why a different one?? annie

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    • @Annie: it is normal practice for a supplementary report to be requested (if necessary) from the same IME, and without having to see that IME again. The case manager simply requests one (by asking additional questions) and pays for the supplementary report.

      You should be aware that your CM must give you , in WRITING, the reason(s) for the need to send you to an IME (again) and that by law they can only send you to an IME if the questions they’re after can not be answered by your treating practitioners. Somethings does not add up here and you should ask hard questions to your CM. Let us know in what state you reside and we can point out the relevant Act section you can copy and paste to your CM. Sounds like s/he is on a doctor shopping spree!

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    • Annie, hang in there girl!  You most probably got bullied because you are a superstar and your boss was threatened by you – doesn’t make much sense I know but that’s because most bully bosses are psychopaths with major psychiatric disorders!   As far as your PTSD –  since most IME’s out there go by outdated DSMV guidelines that don’t even mention workplace bullying, you’ll 99.9% of the time be diagnosed with “adjustment disorder”.

      I worked for a psychopath boss too and and have the same condition, so know what you are going through – although didn’t know about this website (God bless the lady that started it and her co-authors!).   Insurers want you to think you are alone, so you become more depressed and desperate and hopefully just give-up. They know knowledge is power, and could be why this site gets periodically sabotaged!

      Annie – insurers only send you to IMEs to try to cut weekly payments or terminate claims altogether. They have enough dodgy IMEs on the payroll to ensure they get results.  Always check http://www.ratemds.com to check the IME or on this website.   If you are in Vic,  contact WorkCover Assist for advice on legislation.  Check WorkSafe guidelines in your State.  Unfortunately in Vic, it says “reasonable intervals” for IME assessments, but left to insurer to decide what’s “reasonable”.  However 3 weeks would definitely not be considered reasonable intervals.  Supplementary Reports are insurer requested reports from the same IME – used to rephrase questions to get desired responses.   Email Allianz’s FOI Department directly and get a copy of existing IME report.  Allianz cannot send you to a new IME for a supplementary report, it would be a new opinion, new report.  It sounds like the report they have from the IME you’ve just seen is not in their favour and they are doctor shopping. Email your case mis-manager and request and explanation in writing.   WorkCover Victim is right – ask many questions, and get legal advice – don’t just accept what a case manager says or writes.    Also, keep in mind that most case managers are only “the messengers” and are not making the decisions.  Yes some are sadistic and unethical, but most are young & inexperienced  and are getting bullied to get “results”.   If you find speaking to anyone at Allianz distressing – only communicate in writing.

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      Don't give up! June 10, 2013 at 5:08 am
  6. Ask your case manager to send you a copy of the WorkCover guidelines in relation to the use of IMEs they are supposed to follow these guidelines so if they are not then immediately make a complaint to their supervisor and WorkCover. I don’t know what state you are in but that is how it works in NSW. The NSW WorkCover Independent Review Officer (WIRO) can take your complaints and as well CAS 131050 can help you. if you are in another state still ask your CM to supply a copy of the guidelines to you so you know your rights.

    No case manager can cancel your payments over night. There is a legal process so ask for the name of your CM supervisor and ask them what the legal process is and who you can complain to about what is being done to you. All insurers have a complaints policy so get on the website to find out who you can complain to.

    Good luck!!

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    Bashed and bullied June 9, 2013 at 1:58 pm
    • If Allianz is involved then they will not follow legislation unless you complain to Workcover and even then good luck.

      Case managers and their supervisors at Allianz give themselves bonuses for each claim they finilise, so there is no incentive for them to follow the legislation unless they are made to.

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  7. Annie, ask for their view as to why a second IME is needed in writing and immediately lodge a request for Conciliation with the ACCS.  I have found that 9 out of 10 times when you are right, the insurer never goes to conciliation and withdraws before the day.

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    Money Not People June 19, 2013 at 9:54 pm
  8. @WorkCoverVictim, just wondering, do you know if lodging a request for Conciliation counts against a Claims Manager by their company? I have had a prick of a Claims Manager the last year and have lodged some 20 odd Conciliation requests in that time basically for incompetence and have each one settled before the conference in my favour.  Just curious if this would be monitored by the insurer’s technical manager?

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    Money Not People June 20, 2013 at 6:26 pm
    • Good question! I have no idea but would guess so… A conciliation costs around $2000 and includes the medical reports which are paid for by the insurer, which the injured worker wishes to submit as evidence. If the conciliation progresses to a medical panel, it is a flat fee of $5000 for the panel – so $7000. Not too good for a CM’s books and monthly bonuses. I guess most play Russian roulette and hope injured workers give up…= win for the CM.

      As a side note we do know from a very reliable insider’s source that the more conciliations an injured worker files at ACCS the less chances s/he has at a successful outcome. The 1st thing a conciliator does is look at your file (left page No. 1) and see how many times you have been! Some injured workers can- understandably- become a tad “vexatious”, we’re talking about lodging conciliations for trivial matters like a pair of $8 flip flops for an injured toe…and the ACCS does not look favourable upon such injured workers. Always keep you “ammunition” for when you really need it.

      In my 8 yrs of hell I have had 3 or 4 conciliations about big stuff and won each time and more than expected.

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  9. @WorkCover Victim  – I usually save up 3 or 4 gripes and submit an application for Conciliation ever 4 months or so and the conference never happens because the insurer knows they have stuffed up, again !  The Conciliators are toothless anyway.  Their “decisions” are always open to legal challenge which the insurers do all the time.  Conciliators cant “make” either party agree to anything and despite whatever the Conciliator says, the insurer just say “case maintained” so the matter proceeds to the Medical Panel which is where the insurer wants to get you in the first place.

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    Money Not People June 27, 2013 at 11:26 pm
  10. @WorkCover Victim  – I have also heard that the Conciliators in the last year issued about 90 notices of “unarguable cases” in Victoria out of some 6,000+ Conciliation cases.  The unarguable case test is such a low test burden that the insurer’s decision (usually to terminate payments etc) is overturned by the conciliator because it is so flawed.

    The insurers however are allowed to appeal the conciliator’s decision to the Magistrate’s Court and out of the 90 odd notices, 100% were appealed to the Magistrates Court with the insurer arguing they at least had an “arguable case” – a very low burden indeed.

    I dont know how many of these cases the insurers won/lost but here’s the upshot of their actions:

    a)  The Conciliator knows if they make a determination to reinstate payments because the insurer does not have an arguable case, their decision WILL be appealed to the Magistrates Court ie. the insurers are trying to intimidate the conciliators as the insurers have decided to take EVERY conciliator decision to Court.

    b)  The insurers run over the road (literally over the road from Lonsdale St to the Magistrates Court) to argue why the conciliator was wrong.  IF the Magistrate agrees that the insurer has at least an arguable case (ie overturns the conciliator’s determination) the WORKER then has to go to the County Court.

    c)  The worker now in the County Court (with lawyers they have to fund) essentially makes an application for the matter to go to the Medical Panel.  So pretty much every time the county court judge sends the case to the Medical Panel for determination.  Yes that’s right, the WORKER has to apply to the County  Court for the case to go before the Medical Panel (with the insurer’s lawyers opposing this in court at every turn).

    The upshot of this? Conciliators know that it can actually harm the interests of a worker to issue a determination that the insurer’s case is so weak it is “unarguable” because if a Magistrate overturns that decision the worker has to fund an application to the County Court !

    The system has been rigged from the start in favour of insurers (ie big money) against the individual citizen.

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    Money Not People June 27, 2013 at 11:31 pm
  11. @moneynotpeople – these are the kind of facts/stories that need to be shown to the media – this is blatant abuse of power that shows the real story – money over what is right for the injured worker. Stories of injured workers who are in no shape (legal education or physically capable) to argue against the insurers who may not be lawyers, but they sure have more experience with Workcover tactics than an injured worker.

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  12. The purpose of IME’s is for the doctor to find information and to use that against you in favour of the insurer so they dont have to pay your claim.  The IME doctor is not there to provide an unbiased assessment of your injury.

    The IME doctors role is to find/concoct/invent information which they can use to prove that the insurance company’s policy holder (your employer) is not to blame for your injury, hence the insurance company doesnt have to pay you a cent for your injury.

    EG.  You are a 50 year old man who fell at work while lifting heavy boxes.  X-Rays show you have 2 prolapsed discs in your back and a slipped disc in your neck.

    IME Reason 1.  Pre-Existing injury.  The doctor will ask “have you ever had a broken bone”.  “Yes” you reply,  “when I was 19 I broke my ankle skiing, it healed after 6 weeks and never thought of it since”.  The IME will then write in his report something like this “the worker while skiing broke his right ankle. This debilitating trauma resulted in lopsided gait, putting pressure on his hips and lower back.  Years of this going untreated has led to lower back problems and bulging discs which he has today”.

    So, a broken ankle from 30 years ago will be twisted by the IME to explain how it wasn’t a fall at work carrying heavy boxes that led to your bulging vertebrae and thus not covered by WorkCover.

    Reason 2.  Age and lifestyle.  The IME will take your height and weight, which might be 5″10 and 100kgs. The IME could write something like “the worker appeared an obese man and the disc problems he now complains of are not uncommon for a man of his obesity condition and age”.

    That’s right, because you are fat and 50 years old is why you have slipped discs, not a fall onto a concrete floor.

    Reason 3. Faking it.  The IME will ask  you about your movements, restrictions, pain etc.  If in their opinion you can move 14.1 degrees when you should be only able to move 14 degrees, they will write in their report something like “the worker’s mobility and movement when tested is not consistent with their claimed injury”.  ie. you must be a liar.

    And so the IME’s will go on blaming anything BUT your fall as the reason for your injury.  And the IME’s will also question whether you have an injury at all !

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    Money Not People July 1, 2013 at 1:18 am