Most states have a clear Code of Conduct (the Code) that basically outlines what workcover and/or their agents considers to be the standard of conduct and ethical conduct expected from workcover case managers. Whilst one could argue that most case managers are ethical and honest and have no interest in doing anything inappropriate, unfortunately it is all too common for case managers to get too personally involved in the injured worker’s claim and to make appalling decisions…
Things your workcover case manager should never do
Workcover case managers wrongly believe they have to deal with more fraud than other any other insurance lines.For some bizarre reason they are made to believe that all injured workers are fraudsters and “are guilty until proven innocent”. This can cause many workcover case manages to become extremely cynical about any injured worker’s claim that has a so called “red flag” anywhere in the claim process.
The temptation to fight fire with fire can become strong, but the case manager should know better than to get drawn into that trap. Unfortunately, and quite often the case manager will get too personally involved in the injured worker’s claim and make “disturbing decisions”.
If you notice any of the following actions and/or behaviours by your designated workcover case manager, speak up. Ask them why he/she took any of the following actions:
- Not contacting the injured worker: often with the false hope the injured worker will decide not to pursue a presumed -of course- fraudulent claim (can be anything, i.e. request for surgery, MRI, physio etc.) and just go away
- Not returning phone calls : again this is done intentionally with the false hope the injured worker will go away
- Blocking the injured workers email and/or not responding to emails: again as above
- Not explaining the indemnity, entitlements and medical benefits to the injured worker correctly – done to mimimise benefits, entitlements, payments, liability etc.
- Denying a claim without adequate support proof to do so
- Handling a claim with an injured worker they personally knew prior to the worker’s injury (oh yes, this happens!)
- Creating / having a personal relationship with an injured worker during the course of the claim, or after the claim is concluded (oops!). Usually they will try to “befriend” the injured worker and pretend to be their “best mate” as to gain twisted information from the injured worker. A real example involves a man who was befriended (be-flirted really) by his case manager. During one of the (too many) personal calls the friendly case manager asked him “how he was going, lovely” and the injured worker said “oh, I am fine… but the wife is having a hard time..”. The poor man was basically referred to the sad fact that his wife was feeling the immense pressure of the man’s injury and inability to work and provide an income. She was working 2 jobs, raising the kids and looking after him 24/7 as he had a massive back injury and was also very upset that he could no longer engage in sex. The evil “friendly” case manager used her sick personal relationship with this man to add notes (and record conversations) to his claim stating that the injured workers “was fine and obviously had no pain” as “he stated the wife was the problem”. How SICK is that!
- Intentionally not paying or seriously underpaying unrepresented injured workers for a permanent impairment rating. Many case managers will deliberately tell injured workers that they really do not need legal advice, or will forcefully make injured workers sign dodgy settlements under threat that if they don’t they will loose everything (this happens more often that you think!)
- Purposefully under reserving a claim to avoid management review thresholds or reporting thresholds (think BONUS money for the case manager!)
- Recording telephone conversations without the other person’s knowledge nor permission!
- Knowingly taking the recorded statement of an injured worker under the influence of any medication that impairs thinking; i.e immediately after surgery and anesthetic! (happens more often than you think!)
- Deliberately not providing a copy of a recorded statement to the injured worker when requested
- Intentionally not reimbursing mileage expense or other costs paid by the injured worker (i.e pharmacy bills, x-rays, medication paid upfront, authorised appliances, incl household appliances etc – happens very very often!)
- Making a very unrealistically low settlement offer to buy out future medical or indemnity benefits – this is very common. We hear everyday from injured workers who have been scammed and were forced to sign pathetic settlement offers under duress, and by doing so unwittingly signed away all legal rights as well (i.e. for a common law damages claim)
- Deliberately including false or incorrect information in the written summary/details of the workcover claim
- Allowing detrimental information about the injured worker that is not in the least related to the claim to impact the handling of the claim (for example the injured worker has been arrested for domestic abuse; injured worker has “issues” with marriage, …)
- Contacting an injured worker they know is represented by a lawyer and/or who has explicitly requested the case manager refrains from making direct contact (happens all the time – see below)
- Violating the privacy of the injured worker by sharing personal information about the injured with people who do not need or do not have the privilege to know (i.e. talking, email; again this breach of privacy happens more often than you think!)
And then there have been known cases of gross breach of conduct by very greedy case managers such as:
- working on the side for a plaintiff law firm as a second job!
- Deliberately misleading claims management (or self-insured employers) with the aim of getting higher than necessary settlement authority- normally done to just to quickly get rid of the claim!
- Any settlement sharing agreement with the injured worker and/ or the injured worker’s solicitor (oh yes- some are outright evil!)
Whilst we could argue that a single “oversight” or “ethical breach” may not necessarily mean that the case manager is “evil”, multiple oversights or breaches should definitely result in the case manager’s termination of employment.
Below are two REAL letters, written by lawyers, which you can freely adapt and use…
Sample letter to request termination of case manager
We refer to the above matter.
We have received a copy of the exchanges between our client and [case manager name] at your office dated [insert date](copy enclosed for your ease of reference). We were disappointed to note the content of Xchanging’s response to our client ’s request for payment of overdue expenses including the following: “we don’t want to feed her behaviour again”, “once again she is becoming demanding with her emails and I w ill not be responding ”.
We understand that on the foot of previous problems, there was an arrangement made that all communication be made via the treating practitioner. Our client instructs us that this agreement was contravened, as a result of which she lodged a complaint with Xchanging expressing her desire that a new Case Manager be appointed. We do not believe her complaint has yet been acknowledged.
It would seem that there is now an administrative block on [ case manager name] receiving emails directly from our client. Consequently our client has been sending her correspondence to [name]who is the RTW at the [workplace]. Against this backdrop, with respect, we consider the relationship between our client and [case manager] has broken down and this is affecting our client in a very negative way.
We consider that the best course of action in this situation would be for the file to be re-allocated to a new Case Manager.
Sample letter request no direct communication
I write to you in relation to your recent conversation with my wife over the last couple of days but most particularly today’s date at approximately 2.10pm.
You may or may not be aware of my wife’s medical condition and prior direction to the former Insurers GIO. Therefore, I will stipulate and remind you of those at this time yet again. My wife suffers from a serious psychological injury; your continual communications with her only aggravate the situation.
GIO was and now we remind and direct GALLAGHER BASSETT that ALL communications are to go through my wife’s Legal Representatives.
(Legal Reps details)
From this date forth, my wife directs Gallagher Bassett not to communicate with her directly in any way shape or form, no telephone calls, no letters, no emails, not even messenger pigeons NONE WHATSOEVER.
You have been put on notice and failing which my wife will have no other alternative but to apply for an Intervention Order against any personnel from Gallagher Bassett that tries to contact her. She is NOT WELL.
- Unfair and unethical workcover claim practices
- WorkSafe & WorkCover must act with the highest professional standards
- WorkCover must comply with Act regardless of workers’ behaviour
[post inserted by T on behalf of WCV]