One of the IWSN’s main contributors and veteran of a fixed assessment process, Gail, has some sound advice for all injured workers in NSW, and elsewhere. We know that insurers routinely doctor shop until they get the answers that best suit their own purposes and not those of the injured worker. This advice is especially important given that insurers will soon start the process of exposing injured workers to assessments in order to deny or reduce cost liabilities.
Protect yourself from insurance company medical assessors
Gail writes:
What ever the injuries, if you are not improving, then it is essential to get a referral to a treating medical specialist to properly assess your injuries. They can order the MRIs and other tests and once you are properly diagnosed with regard to what your injuries are and you have treatment needed worked out it is much harder for any insurance assessor to overlook this evidence.
Your nominated treating doctor usually knows a good specialist to refer you to and if they write the referral and send it to both the specialist and the insurer the specialist will usually get permission for you from the insurer. If the insurer refuses, then go anyway and use Medicare. Medicare will get their costs back later if you get a lump sum and then you claim it back from the insurer.
It is best if you ring your case manager to get permission for any treatment and keep them fully informed so when the request from the treating doctor comes in they will know.
Make sure you get your specialist to explain exactly what your injuries are and how they will affect you. We used to have a list to read from. Dates of injury, treatment, imaging studies etc.
There are certain things the assessor must ask and do so the more you know the better off you are.
The new assessor information states the assessor must have qualifications in the area of your injury so if you are sent to a colorectal surgeon for a shoulder injury ask to be sent to someone qualified and ring claims assistance if the insurer refuses.
When you see a specialist for treatment they have to write a report to your nominated treating doctor and to the insurer so ask them to put the recommended treatment in the report and ask them to send you a copy of the report.
You can also get second opinions and use medicare if you need to. The more accurate your reports from your specialists the better your evidence is.
You will then have proper medical evidence if you are sent for a work capacity assessment. I f you are sent to a work capacity assessor they can say you are able to do some work you would not be able to do in your area so be really clear about whether or not you think you are ready to return to work and if you be very clear about what you might be able to do. When filling out any forms they give you don’t put down you are interested in something you know will not be possible for you to do.
I know a young woman who put down she liked children and liked people and they said she could become a teacher or a psychologist, completely overlooking the fact that she was in constant pain and could not use a computer due to having one arm she couldn’t use. They also overlooked the four or more years at Uni when she didn’t have any school levels to actually get into the courses. The also overlooked the two small daughters and husband that ran out when things got tough. She also had domestic assistance so how unreal was the suggestion she go off to uni to become a psychologist or teacher when she can’t even put out washing or clean without help?.
The new laws don’t care that there are no jobs they suggest available where you live so be aware of that.
Ask the assessor to discuss what might happen if there is a great possibility of deterioration from a return to work. If your surgeon says you will deteriorate or aggravate your injury with certain types of work tell you must tell the work capacity assessor.
You can now be made fit for work that could never be available in your area and after a certain time without work you lose weekly payments and have to go on Centre-link. You have no legal support for this but good medical reports stating your exact restrictions and injuries can be used to send to the insurer to ask for a review.
We are all on shaky ground. My insurer is at least waiting till I have all my medical assessments from my treating spinal surgeon to decide if I need another medical assessment for percentage of injury before sending me for the work capacity testing.
Good luck, we will all need it to deal with all the extra assessments and God help us all if we all get told we can get a job dusting for an hour a day like my husband was told. He was a mechanic !!
There will be a lot to learn so maybe a booklet could be written to help people once more is known. Lots of people who have had assessments would be able to help with support and advice.
[Workcover victim: whilst virtually all of this extremely useful information applies to all states, it is worth reminding all injured sods that the workers comp legislation varies from state to state. Given that we are staring to cover the whole of Australia, I believe it is important we make reference to the state where the relevant legislation applies, as not to confuse people too much]
Shortlink: http://wp.me/p1MA9G-2V6
Thank you for such an excellent and informative article, Gail and John, muchly appreciated. Knowledge is indeed the only POWER we have (at this stage) and the more we know about the many dirty tactics and scams used by insurance companies the better we can protect ourselves ans our basic, legitimate rights!
It’s shocking to what length some case managers and unethical “independent” medical assessors will go to. Not long ago a bewildered severely injured worker, who is unable to even get dressed on her own, shower, toilet or eat, was told by a horrible IME that “she was surely still able to lick envelopes”. I kid you not! Her “capacity assessment” showed her “fit” to work… “4 hours per week minimum as a administrative assistant, doing paper work, such as… filling envelopes”.
Various other dirty tactics are used as well, such as literally “bypassing” injured workers’ physical injuries if they have been diagnosed with “secondary psych injuries” such as depression, anxiety, PTSD, adjustment disorder.
About 2 years ago, shortly after my entire shoulder reconstruction broke down (and a request was made for further major surgery), my case manager sent me to a IME shrink. This shrink was extremely unethical and highly unprofessional, however the main issue was that my case manager had deliberately omitted to provide the physical medical reports of my “status” and had demanded an psych assessment, suggesting “a psychological overlay” in her “cover letter”, with a “view of engaging in rehab and return to work”.
This IME hired gun shrink had no interest whatsoever in my physical condition and acute deterioration (requiring a 7th massive reconstruction). My case manager had not provided any medical evidence of my physical condition and deterioration (the only reference was of 2006) and had also emailed me “that she was not interested in my physical condition!
That I was certified totally unfit for ANY work from a physical point of view (by a top upper limb surgeon and IME Ortho surgeons) did not count either.
That hired gun stated that “I should undertake volunteer work with a view to RTW”.
Now, you can just imagine what sh*t this caused…both my treating psychologist and psychiatrist were harassed for months by the case manager to provide “commentary” and to “facilitate volunteer work”…
In the end, as you can well imagine, this caused me to suffer from yet another major emotional breakdown and eventually I was sent and re-sent to several other IME shrinks who all certified me unfit for ANY work for “years” from a psychological perspective. In addition to remaining totally unfit for “the forseeable future” from a physical perspective.
It is just sickening. Insane!
Thanks God for my own treaters and some decent INEs who rightly believed that nobody in “their right mind” would/could “facilitate volunteer work” on a severely injured worker who’s arm is literally hanging out of its socket.
Since that day, I ALWAYS carry my OWN medical file with me when I am send to an IME or any kind of “assessment” and have copies made in advance of all relevant up-to-date medical reports, which I can simply hand over.
You would be amazed at how little the insurer sends to the “assessor” and how they totally mis-represent the medical evidence.
By the way, after 7 massive reconstructions, incl. transplants and terrible complications, my “diagnosis” remains “bruised R shoulder” when they send me to an “assessment”!
This SICK system is making us all more and more sick.
It’s a heavy handed and brutal form of “gas lighting” that these insurance companies are engaged in.
Insane systems are making me feel like I am the one going insane.
Simply saving all these Blogs from John of affected workcover claimants is a good pathway to a booklet on snippets of vital future evidence needed.
I assume very soon most of the workers would be sent for work capacity assessment and most of them would be at risk of losing their entitlements unless they provide detailed information during such examination.
Like in every profession, there are good and bad people in this profession too. If you are lucky enough, you might find some real gems, working as AMEs and deserve our salute. However, in my opinion, they are not many as most of them are either tempted (for obvious reasons) or brainwashed. I remember one such AME who nearly assaulted me physically during such medical assessment. I was shocked to learn how low these people could go. However, as I produced more and more medical evidence, his facial expression changed. By the end of the assessment, he was red faced and looked exhausted as if he lost the battle.
Even though, I believe, medical reports of AMEs are not the end of the matter as AMEs are humans too, and have limited knowledge. They can only express their opinion which can be overturned by a genuine report of another specialist. Truth is a very powerful tool which can make any wrongdoer blind at the end. Remember, a truthful and factual report will always be supported by all no matter where you are.
Interesting thing is that such examiners have to perform their duties within their professional boundary. Mostly, they are a scared lot as they have to walk on the edge of a sword and aware of the risks while crossing the boundary. They cannot ignore or change strong medical evidence. Sometimes, they give preference to the weakest evidence to write a report against you. This is your job to get the favourable evidence recorded in the report. They just cannot ignore that evidence if a support person is sitting next to you and taking notes.
Regarding the medical costs this is what NSW workcover has to say:
“This provision is the result of an amendment to the Bill. It appears this change will mean anyone taking a worker’s compensation dispute to the Workers Compensation Commission will need to pay their own legal costs. A decision on its commencement date has not been made yet.”
As a decision on its commencement date has not been made yet, I assume, all claims made till today, whether disputed or not, are covered. This is not a job of the injured worker to set a commencement date. And just like a red light camera, they must give you ample warning before that happens, if they have any respect towards the existing laws. Also, it would not be easy for them to quash the previous court orders as it would open the floodgate of more lawsuits. All the best and take care.
When u see these IME ” specialists ” ask for them in writing or ask them to show you evidence of their specialist qualifications before you start any examinations from them.
These people have to be specialists in the area of expertise of your injury including psychological injuries too.
Just being a ” clinical Psychologist ” with Honors doesn’t mean they are a specialist in the particular type of psychological injury you have and also medical as well.
If they don’t tell you or they get evasive you must say that as this person is assessing your condition for insurance and work purposes you are entitled to this information and that as you have presented yourself for this examination you are entitled to a fair and honest assessment from a specialist in the field of your injury .
Also when you get to the assessment you may have to sign in at the front desk. If you do ask for a copy of this and have the secretary to sign it as well . Get a copy as it is proof of you attending!!
If you find the assessor refuses to give you any qualifications and produce them then say that you will be lodging a complaint with WorkCover and the medical board as they are required by law to tell you.
Then get up and say thank you and leave.
If you do this type of action please have a friend or someone with you as a support for a witness.
All you are required to do is present yourself for an assessment .
If you are not satisfied with the person concerned inform them of this and state you will complain about them.
It’s interesting when the insurance company is told by the IME !!!
Also, I would ask the IME if they assessing you for a physical injury ie back, shoulder etc, ask them before they start what medical manual do they use, is this manual the latest one and if not that you are insisting that this IME use the latest medical manual for an assessment.
If they say that they are doing this by WorkCover policies etc , say that unless they use the most current medical manual to assess you then you will take the matter further and complain to the medical board of unprofessional behavior.
When you are assessed for a psychological injury the IME’s use the latest manual ( DSM IV- TR ) .
The Insurance Company case managers have no idea what to do when this happens.
You have done what you have been told to do and it’s not your fault if the assessor is inept .
Apologies.
The second last paragraph should be before the one before it! Sorry everyone. Not well this morning.