Why on earth would injured workers commit deceit, fraud or malinger?

injured-worker-fraud

According to tabloids, government, workcover and their agents it is “not rare” to learn that an injured worker who is unable to work, is actually “gainfully employed” while claiming workers compensation and that malingering and corruption is a “significant concern”.

Why on earth would injured workers commit deceit, fraud or malinger?

With 8 years of being trapped in the workers compensation system, I conclude that the system is in fact rorted by insurance companies; doctors and some lawyers! Fact is workcover leeching off the system costs taxpayers far more than injured workers.

Some would have us believe that injured workers are “rorting” the system, and yeah, perhaps less than 1% of injured workers try to do so, but I bet you know how hard it is – virtually impossible to do so!

Take for example the all to common occurring:

  • workcover insurance companies shaft injured workers with “their interpretation” of the compensation Act – for example, how many times have you [the injured worker] been sent for an “assessment” with a so called independent medical doctor on the false pretexts that “your own doctor has not provided the information”? Or take for example those injured workers who were assessed has having permanent injuries and have been compensated with a [tiny] lump sum, for those permanent injuries – now why do insurance companies still send you to independent assessments given that you have already received a lump sum for the proven permanent injuries you are suffering? They’re permanent, duh!
  • How about case managers and insurance doctors downgrading your permanent injuries? How does that work?
  • How about so called independent doctors (IMEs)  giving false ans misleading levels of impairment?
  • Let’s say you have a back injury – you will be assessed whether there is any loss of use and or permanent impairment of your back. Depending how bad your back injury is you may get 5 or 10%. Most likely insurers and IMEs will go to great lengths to prove that you back injury was in fact “pre-existing” [fact is all people when they get older have some sort of “degeneration” of their spine! That’s just part of getting older.]. You really can’t “fake” it because x-rays, scans, MRIs will PROVE it. So this means that you can’t expect to have a “bruised back” [or leg or arm,…] and expect to be on workcover long term or get a “large” payout, simply not possible.
  • Fact is if the insurer pays for an “assessment” or a “report”, then chances are that doctor, rehab provider, etc. is biased. You do not cut off the hand that feeds you. I am pretty confident that all (99%) doctors have either been paid or been told by the government not to give legit (high) levels of impairment
  • Medical certificates: how is it that when you are severely injured and end up on workcover long term with PERMANENT injuries, then you still have to supply medical certificates of incapacity every 28 days? Given that the workcover insurer knows very well that you suffer permanent injuries [some injured workers may already have received a lump sum for those permanent injuries] so why is it that further medical certificates are required? Permanent injuries don’t go away, hellooo! So why on earth the need for ongoing medical certificates and ongoing independent medical examinations? Why? Simple, this is a well know tactic used by workcover simply to give you the “sh*ts” in a desperate attempt to return you to work, at all cost.
  • Why do case managers organise “conferences” with your treating doctor, even though you have been PROVEN to have been permanently injured? Simply in an attempt to have your certificate of capacity amended folks. Insurance companies don’t care if you are really unfit or unable to work and really don’t give a toss if you were to return to work (under duress) and re-injure yourself. They will blame you for “agreeing to RTW”!
  • Did you know that case managers, who for example attend a conference with you and your doctor do so in order to make a case. Check out this very real story: a worker who suffered a bad back injury (and was assessed as 35% total body impairment) attended the required “conference” with his case manager and treating doctor. He was feeling very stressed that he had to attend. He could not obntain taxi travel from the insurer and is simply unable to cope with public transport. So he did the impossible and drove himself (20 minute trip). He took more pain medication so he could drag himself to the “meeting”. In agony he sat in the waiting room for more than 30 minutes. Guess what, the case manager stated to the doctor that “hey, given that the injured worker drove here (20 min driving) and was “able” to sit in the waiting room for 30 minutes straight, he is clearly fit for some work, would you not agree?”. Bang! What are you supposed to do? Lie on the floor? YES! If your pain is so severe that you have trouble sitting in a chair in a waiting room (be it your own treater, and IME or a “conference”) by all means, go and lie on the floor!
  • We know of cases where a case manager has made a point that because an injured worker is capable of attending the doctor every month for a medical certificate, they can work! If you happen to drive your car to an appointment, they’ll say you are “fit to work as a courier”!
  • And what about “rehab”? Attending rehab service providers and vocational assessments. On most occasions the rehabber will tell you that in order “to participate” you would need to have your medical certificate changed. Then you beg your doctor do this, and start looking for suitable work, which gets repeatedly knocked off because it is “outside your restrictions” or prospective employers do not want to take the risk hiring you. Rehabbers will drag your “rehab” out so they too can make a good buck from workcover. And then, suddenly the insurance stops “rehab” and “vocational guidance” – WTF? Here you are trying to return to work but, sorry mate, see you later, your certificate was changed to “fit for some work” under FALSE pretenses- and you are cut off workcover – helloooo! How many times were you refused retraining? A TAFE course? Then they write to you “because there is no foreseeable return to work for you, we are not prepared to fund this course”. Do they really want injured workers to return to work? But they keep sending you to IMEs to “see if you are fit for work”? Especially when you have proven permanent injuries… duh?
  • Provide a home address and chances are someone from the insurance will be videoing you. Have nothing to hide, sure! Walk to the post box and try to bend over to pick up the newspaper and you’re gone! Walk to the corner shop and carry a bag home and you’re gone! They are utter vultures trying to “catch you out” in an ognoing attempt to get you off their ($$$) books!
  • Injured workers “rorting” the system? Think again! You may be able to “rort” the system for a week or two, but then if X-rays, scans, MRIs can’t PROVE that you have [semi]permanent injuries a massive “red flag” will be waving at you! And then you would still need to fool the insurer’s doctor and the insurer – and whilst they VIDEO you!
  • As you can see it is virtually impossible to “rort” the system as an “injured worker” – and why on earth would you want to “rort” the system? Money-wise its definitely not worth it. Sitting at home and watching a terrible midday movie again? It’s not living! Your bills and mortgage don’t stop, rent, rego is not free so why would you want to love a pauper’s life along with having to deal with a horrible insurance company? Lump sum payment? Forget it, first of all you will be assessed by biased insurance doctors and have your “injury” downgraded if not entirely dismissed should you not have X-ray, scan, MRI PROOF. Furthermore a lump sum is a very small amount of money, the amount set in a table. For a certain % impairment you get a certain amount of money. Even if you were a total write-off you could expect just about $50,000. Most injured workers don’t even qualify for a pathetic lump sum (i.e. no lumpsum if you are less than 10% impaired). Many seriously injured workers get ZERO permanent impairment, because pain does not rate!
  • The workcover system has been designed, solely, to force injured workers (regardless of their status/condition) back to work and at any cost. Fact is there are NO provisions under the workcover Act for injured workers who simply cannot return to work because of the severity of their permanent injuries. This is where case managers have been brainwashed and made to believe that, yeah, even totally paralysed people in wheelchairs can “work”, for example they can have a saxophone glued to their mouth and sit at train stations and wait for handouts; or quadriplegics “licking envelopes” to say they are “gainfully employed”. This brainwashing technique simply says that there is no such a thing as a “totally disabled” person.

A little more about the so called injured workers’ fraud

Fraud implies intent: intent to defraud, intent to misconstrue facts and to hide it from somebody to get something. There are quite a few legit injured workers who have been accused of fraud but who just may have made legitimate mistakes. Take for example, a severely injured worker who is asked by his treating psychologist/psychiatrist to reconnect with the world (socialise). The injured worker happens to be religious and decided that volunteering for church on Sunday morning (i.e. helping collect money, light candles, make coffee or sit at a “stall for the poor selling $1 made home scarfs”). Now this injured worker is accused for fraud – how is this person to realise that unpaid volunteering at the church would be “considered work”?

The most pathetic of accused “fraudsters” is perhaps the fact that they may have made a few hundred dollars here and there, and for that they may have been arrested, lost all their benefits and pay back fines! Most “fraudsters” have legitimate claims!

Yet statistics show time and time again that at least 10 times as much money has been recovered by prosecuting employers for not carrying insurance or for misclassifying payroll!

Now what about people who were working and had a little side business selling some goods on eBay after hours? When they are injured the law says insurers can not consider the money they made from eBay sales while they were working to determine the injured worker’s overall wages (PIAWE). Yet if they are still doing that after they are injured, the court, judges, insurers, case managers etc will consider those to be wages (income) and it become a FRAUD problem! Now how does that work?

I still remember the following article appearing in a NSW news paper in March 2012:

Rorts-and-All View of compensation

A WORKER who claimed tinnitus because of excess use of her Blackberry phone has received $1.2 million in workers compensation over five years under what the government calls antiquated WorkCover laws.

The woman received her settlement and ongoing payments because of psychological workplace stress after the incident.

Another man sustained injury to his finger on his non-dominant hand five years ago, reported the incident months later, and has since received workers compensation, physiotherapy, hydrotherapy, pilates, psychological and psychiatric treatment, holistic treatment and a gym program – valued at $400,000.

A bar attendant who intervened in a fight outside his workplace between two men who were not patrons, suffered minor bruising and has since received almost $300,000 for psychological and physiological trauma.

Finance Minister Greg Pearce’s office rolled out the examples in a bid to show why the workers compensation scheme needs reform.

Mr Pearce said, under the scheme, last year more than $100,000 was spent on remedial massage and $1.3 million on physiotherapy for people injured more than three years ago who are deemed fit to work. More than $440 million had been spent on medical services for people injured more than three years ago who are deemed fit to work.

These cases were exposed by the Finance Minister (Pierce) of NSW….

Now, now, now, first of all I believe these claims are totally false or at the very least grossly exaggerated of misleading. They are possibly completely fabricated in the attempt to change the workers compensation NSW Act.

For this to be true, the injured workers would have to fool their own doctors, but they would also need to fool the insurance doctor, the insurer, medico-legals and then also convince a lawyer that they have a legitimate case, then go to court, sue for negligence and win. I don’t think so…

But, in the remote chance that these claims are true, then all I could conclude is that hundreds of thousands injured workers have missed out on compensation they should have clearly been entitled to! The insurance agents and the government would be BROKE!

These extreme cases above would have to have gone under the Common Law Damages Claim… and yet how come the MAJORITY of seriously injured workers are NOT entitled to a common law claim, but are forced to stay in the workers comp system, with a tiny weekly pay and some medical treatments paid for? So  the majority of seriously injured workers are clearly being ripped off, right?

Under Common Law you would sue your employer for negligence (their fault for your injury). You would need to prove that your employer was either negligent or at fault. If successful (rare cases) then you may get let’s say $500,000 in compensation. But for the majority of the seriously injured workers this same injury may only get you $50,000 (lump sum), weekly pay of less than half your salary and then “the pension”. Great isn’t it? Who is being rorted here? Yep, the injured worker over and over again!

It certainly appears that the Act exists solely to protect insurance companies and employers! For example, did you know that you can only proceed with a common law damages claim in NSW before 3 years (from the date of your injury) has lapsed? So, how come? Those of us who are seriously and PERMANENTLY injured – injured for LIFE – can only start common law within 3 years – does this mean employers and insurance companies live in utter fear that one day we may serve them with a common law notice? Is that why the 3 years are in place? I wonder – think about it.

There are other extremely important areas that you need to seriously consider:

If video surveillance demonstrates that the injured worker is working beyond the limits set forth by the authorised /treating physician, why is the injured workers doing this?

  1. Is the injured worker  forcing himself to work beyond physical limits to keep from being bored, spiralling downwards into an even more serious depression, or trying to be somewhat productive in his/her debilitated life? Is the injured worker extending him/herself as an attempt to participate in his/her own work-strengthening? Has the injured worker been encouraged to attempt some productivity every day, despite severe pain (i.e by their treating psychologist/psychiatrist)?
  2.  Or, as case managers appear to suspect, is the injured worker clearly demonstrating a functional capacity far beyond what his physician believes it to be? Think again about the example of the severely injured worker with a back injury, FORCED to attend and sit in a waiting room for 30 minutes.
  3.  Is someone recommending to the injured worker that he/she remains in his residence, not venture out, and be on guard for investigators documenting his every behavior? Would YOU be surprised to know that many injured workers are not only severely depressed, that they have lost their social circle and are socially isolated and that, yes, many have become totally paranoid, constantly looking over their shoulders, because of the sheer fear that they will be spied upon 24/7 and that “by doing someting/anything” the insurer will state they are not as “bad as they portray to be”, they are accused of malingering because they happen to smile at their kid’s birthday party; or worse, that insurers will believe “it’s all in their head”. But, on the other hand, if you do not leave the house, “they” will go to great lengths to state “you are never at home – so you must be working a second job somewhere illegally”…
  4. Is someone advising the patient to appear as though his limitations are more severe than they truly are? Is it a surprise that, when you are accused over and over again of being a fraudster, milker, malingerer, whatever, and that you are constantly being spied upon, that you may portray your limitations more clearly?

Fact is many injured workers receive a large amount of misinformation and disinformation that results in their making poor decisions.

Such advice most often comes from within and outside the family from those who are truly ill-informed as to what a person needs in life, and beyond finances. This advice comes from the seriously naive position that all of life’s ills are resolved financially and that the patient’s self-image and self-worth have a monetary rather than emotional value.

Those ill-informed, naive people have NO clue, they do not know what they are talking about – for there is no money, or at least, only very little (a lumpsum barely covers your accrued debts, you loss of wages etc) and in order to obtain “that lump sum” they forget to tell you that you will be dragged to hell.

What an injured worker needs to know is that “you may have permanent limitations and chronic pain despite any care that is provided.

While injured workers (and 1% “fakers”) are being told that there is a financial value to this suffering, in fact, there is none.

Any little money you may receive will eventually be depleted, and you will continue in your life with your pain, disability and symptoms.

What seriously  injured workers need are activities that make them feel productive, more complete, and a value to themselves and others. They need to be encouraged to do as much as they can (on good and bad days), to extend beyond their limits, and to establish a post-injury life that offers some degree of fulfillment – yet the workcover system does not even allow injured workers this “freedom”.

 

[Post pre-dictated and entered on behalf of WCV]

 

 

8 Responses to “Why on earth would injured workers commit deceit, fraud or malinger?”

  1. Check out this pathetic PI website:
    Makes me want to puke!

    What does WorkCover Fraud entail?
    The definition of fraud

    The WorkCover definition of fraud is: ‘obtaining by deception or dishonest means money or any other benefit’.
    Worker fraud

    There are two categories of worker fraud:

    Where the worker does not have a compensable injury or has an injury that does not fall within the ambit of the Act for example:
    The injury did not arise out of, or in the course of, employment,
    The worker sustained no injury, but feigns the symptoms to seek compensation,
    Received an injury during sporting activities, and then claims it occurred at work.

    In such cases, there is an obvious intent to gain a benefit to which they are not entitled. This type of fraud, if proven, invalidates the whole claim.

    “Situation fraud” occurs when the worker has a compensable injury, but at some time during the management of their claim, they obtain benefits to which they are not entitled. This usually involves the provision of misleading information to the case manager. For example:
    The worker may return to employment while claiming full compensation,
    May claim for home help when they are capable of looking after themselves,

    While there is still intent by the injured worker to deceive, this fraud does not invalidate the whole claim, but, if proven, may result in a reduction in the claim.

    Here are some indicators that you can use as a guide in detecting possible worker fraud:

    Timing of the incident
    If the alleged injury occurs first thing on a Monday morning, or late Friday afternoon (and is not reported until Monday), there’s a chance that the injury may have been incurred over the weekend during sporting activities.

    Change of employment
    If the reported incident occurred immediately before or after the end of a big project, an industrial dispute, job termination, lay-off, at the conclusion of seasonal work or a short-term or contract, you should consider investigating.

    Vacation leave issues
    If the alleged injury occurs a few days before or after a holiday, or after holiday leave has been refused the claim might warrant an investigation.

    The incident occurs without a credible witness
    Where there was no witnesses to the accident, and the injured worker’s own description does not logically support the cause of the injury; or in cases where the witness has a poor record with compensable injuries and provides a questionable version of the incident, investigation may become necessary.

    Claims history
    If the injured worker has a history of numerous suspicious claims, or the medical provider or legal consultant has a past history of handling suspect claims, there is cause for an investigation.

    Discrepancies in the reports
    When the worker’s description of the incident conflicts with the medical reports; or the employer’s initial report of the accident does not match the injury or location, or in cases where there are differing descriptions of how the injury occurred, an investigation could shed light the actual events.

    Difficulty contacting the claimant
    If the case manager experiences difficulty contacting the worker at home when they are allegedly disabled, or an answering machine or their partner/family members continually act as point of for the injured employee, there may be reason to suspect that the employee is absent from home.

    Diagnosis and treatment
    When the injured worker refuses to undergo a diagnostic procedure that will confirm the nature or extent of the injury, or if the worker travels to seek medical treatment in another area from his/her home or workplace, or has no ongoing treatment, an investigation may be called for.

    Disgruntled employee
    If the injured worker is about to be or has been retrenched, demoted or passed over for promotion, the claim may be suspect and warrant an investigation.

    Referral or tip off
    When information is received from a co-worker, spouse, domestic partner, friend or any other source, that sheds suspicion on the claim, an investigation is in order.

    Work history
    If the injured worker has a history of unstable employment or drug and alcohol abuse, or has a poor attendance or sick leave record, an investigation is recommended.

    • I spent so much of my time and energy in the system fighting against what I can only see as insurer fraud, now that I know what happened to CGU (contract not renewed in Victoria due to million dollar rorting of “bonus” payments). They made many errors with payments over the years, sometimes in my favour, and whenever I would write and try to clear up the matter, they would simply ignore me! they kept a $500 refund from me for years through this brick wall technique! Then they sent me a letter telling me i had received an overpayment (another financial irregularity I had been drawing to their attention for over twelve months) and that if I didn’t repay it immediately, they would take me to court! The overpayment turned out to be due to my Psychiatrist for treatment. I never claimed it, and all other payments were made direct to the Psychiatrist. How did it end up in my account? Go figure! Did I get paid interest on that long overdue refund…..Nooo! they were threatening me with court even while they were still withholding the $500 refund!

  2. Im of to malinger wait for my pittance to be paid and then back to malingering

  3. We lose so much more than just our financial health when we lose the capacity to work. There’s all those other things we get through work. The sense of being able and productive; the sense of contributing to something bigger than ourself; the contact and feed-back from other adults; the endorphin joys of accomplishment and self value. We lose this when we get locked out of society by our injuries. And in losing these possibilities, we lose our senses of future and belonging. Noone in their right mind would trade a loved job for the traumas of Workover.

  4. Every thing you say resonates with all my own sick-making experiences in this Workover system. My claim was denied for a year, and I was unable to access psych treatment immeddiately which made my mental condition a whole lot worse. I’ve experienced the insurers holding up the repayment of a substantial medication claim over a number of years. I’ve had to fight and wait for rehab support, and have paid all my own rehab costs for several years now. I think my GP bills my medical to Medicare, and the insurer pays for my weekly psychologist consult. It’s a very bare level care for my psych injuries, yet the insurer is currently hoping to take that away too! I’ve been completely denied return to work assistance even though it was included in my settlement contract! I get sent to IME examinations even though the insurer is aware that these examinations always cause a severe exacerbation of the PTSD and Major Depression. I get asked legal questions when I’m in these examinations – what is that about?
    Workoveer, it’s corrupt and its cruel, and it shouldn’t exist like this.

    • Oh my goodness….you are more or less explaining everything that I am feeling and experiencing through workcover. I was involved in a MVA on the 21/6/12 and have had nothing but problems with my neck, shoulder and back. I have done everything that the specialist and GP have recommended but I am finding that workcover is not listening to them or myself. I am still not able to work and I am now suffering from depression thanks to the constant harrasment from my case supervisor. Is receiving 6 phone calls in one day normal???…then asking me where I am…oh you sound like you are in a mall….really…how can that be when you have rung my home number?? Also trying to send me for treatment that the specialist and GP have not approved. Insulting my doctor by stipulating that he only cures flus….when did he do his universty to become a qualified medical doctor. Also trying to get me working again when they clearly state that I am not able to. I have now had to get my solicitor involved for the constant harrasment has made me sink deaper into depression. Do they really think that we want to be in this situation??…I want nothing more that to have my life back and at this stage I dont see any light at the end of the tunnel. All I do is cry and feel as though I am not able to leave the house, even though there appointed Psychologist is encourging me to do so. I feel very alone and bullied by a system and case supervisors that do not listen or read what the specialist state. They are making me feel like I am the criminal…I did not ask for someone to run into the back of my car at 60klms an hour, I also did not ask or deserve these injuries that I have. All I want is my life back and not to be harrased and made to feel like a useless human being who does not know what is good for me.

  5. What an excellent article, says it all, congrats !!! Reminds me of the rehab provider who organised a meeting with my friend and her doctor. She failed to tell my friend about it and when she did not appear she rang her and demanded she turn up as she stated she ‘was getting her doctor to change the certificate as you can’t be unfit forever’. This is not just unethical, it is fraudulent but it is so typical of agents of insurance companies.

  6. Yeah I am totally sick of hearing about injured workers “fraud” – makes me SICK!