Injured worker aggravates work injury after fall at home – weekly pay ceased!

care-factor-zero-worksafe-vic

“Carefactor 0” is a Victorian-based  injured worker, who suffered a severe cervical spine (neck) injury at work, for which she underwent surgery but is left with ongoing motor issues affecting her upper and lower limbs. One of her main issues, apart from ongoing pain, is that she has difficulty walking due to residual weakness in her legs. When she stands up and takes a few steps, she feels – at times – that her legs “aren’t there” and falls!

The worst part of “Carefactor 0’s” story is that, following a more recent and serious fall (requiring hospital admission), she has been denied further workcover benefits, including weekly payments based on the allegation of workcover (the insurer) that her (most recent) fall aggravated her original workplace injury!

Injured worker aggravates work injury after fall at home – weekly pay ceased!

Injured worker “Carefactor 0″‘s story

Note: for privacy reasons some words have been censored and parts of the story have been omitted

I am a [censored]yr old female, my nickname (Carefactor 0) says it all….I have a 0 care factor at present when it comes to the current workcover (vic) system.

I was injured in March, 20xx. I was at first miss diagnosed as having a shoulder injury, only to find about x months after ongoing shoulder treatment and worsening symptoms a CT scan discovered I had two severely prolapsed discs in my cervical spine. I had been receiving treatment prior to this for radiating pain from the disc prolapses. I was referred to a neurosurgeon, who suggested [ injections] as an option to surgery, My [level] disc had prolapsed sideways into the nerve root for my x arm. The disc above had prolapsed posteriorly [level of disc] towards my spinal cord, at this stage not actually compressing the spinal cord but was compressing the fluid sac protecting my spinal cord. I received the [ injection] for [level disc] and had an allergic reaction to the steroid which caused major inflammation around the injured area and increased my pain levels and motor skills of my left arm to practically useless.

In August, 20xx my neurosurgeon decided to operate on one disc only, the [one] which was the disc interfering with and causing severe pain and motor skill issues in my x arm. Not to mention the uncontrollable neck and shoulder pain 24/7.

I would confidently say since [month of injury], 20xx when my injury occurred I have not had 1 proper night’s sleep since.

I tried to return to work after this surgery, but as soon as I tried to perform ongoing duties or movement of any nature my pain levels shot through the roof again and I had to stop working. What concerned me the most, the pain was not just in my neck, shoulders and left arm anymore.

I was having difficulty walking,standing for to long, sitting for to long, using both my arms due to pain, weakness, and un-coordination.

I had no idea what was happening to me. My physio monitored my symptoms for some months and these symptoms were slowly becoming worse.

I was sent to see a neurosurgeon after my physio discovered I couldn’t [do certain exercises], due to co-ordination problems.

By the way my first neurosurgeon discharged me x months after my first surgery. As he felt I had no ongoing symptoms and was just trying to get out of work.

The neurosurgeon that I was referred to by my physio was excellent. MRI scans and X-rays were requested immediately, he fully examined me and had major concerns that I had a serious neurological problem at hand.

I struggled through another few months with no work capacity awaiting tests and results to be available to my neurologist.

My condition was worsening on a weekly basis. By the time I eventually had my follow up appointment with my neurosurgeon I could hardly walk, I shuffled like an old lady, I could not use my arms, I was not sleeping, I was experiencing the worst pain, numbness, tingling, shooting pain and burning in my arms, legs, hands, feet, neck and shoulders I had ever known.

I was totally depressed, feeling totally useless to myself and my family, distressed and suffering anxiety. Along with all the physical symptoms.

My GP put me on anti-depressants, which I am still taking today.

My neurosurgeon after receiving my scan results and re-examining me came to an immediate conclusion that due to how quickly my symptoms were escalating I needed immediate emergency surgery. The [level] disc was now compressing my spinal cord and my neck was very unstable. The injury was only going to get worse not improve, without the surgical intervention.

The surgery was preformed in [month], 20xx. I would classify the surgery as successful. I have had moderate improvement in my condition since surgery. Although I am by no means fixed.

I still have mild spinal cord compression, I have difficulty walking and performing any task that takes more than 5 to maybe 10/15mins is out of the question. I have had several falls since the last surgery, where I literally go to stand up or take a step and its as if my legs aren’t there, amongst all my other ongoing pain and motor issues with my arms, hands, legs and feet.

The continuing pain in my neck and shoulders (well what do I say; I have accepted to a point that this is probably as good as it will get). I am sorry for the rambling.

In [month], 20xx I had made arrangements with my, work, doctors and physio to try to return to work as my medical team were hoping some of my ongoing symptoms may have been due to non activity for such a long period of time. I agreed, it was worth a shot. I’m not a quitter and I will try anything especially when it comes to pain or inability to preform simple everyday task. I returned to work for x weeks on light duties and boy, my body did not like it at all. I spoke with my physio who came along to my work and sat down with my back to work co-ordinator and he explained my current fitness level and ongoing medical concerns and we all worked out a more appropriate return to work plan.

Hoping upon hope, I would be able to slowly and gradually get back to work. Wronnnnnnnng. I was to start my new revised back to work plan on [date], 20xx. unfortunately on the [a few days prior], 20xx I had another fall, this time I was in my backyard and fell backwards instead of forwards like my previous falls.

I fell straight back [description of how it actually happened] on the base of my spine (lower back), ouchy it really hurt. Unfortunately The following day I had to present at hospital as the severe bruising had temporarily affected the mass of nerves in my buttocks and my bladder shut down. All x-rays, ct scans, MRIand ultrasounds preformed in hospital for my lower back came back clear. I spent x days in hospital with a catheter inserted until the bruising and inflammation around the nerves in my buttocks settled and I was able to use my bladder again.(please this injury and stay in hospital were not related to my work injury).

The fall which caused this unfortunate situation was due to ongoing issues I was and still are having with my work related injury,falling, as my legs go on me without any pre warning.
Since this fall I have been on a roller coaster ride with my employer, who by the way are self insured. I have received no work cover payments, based on the fact that they are now saying my fall aggravated my work cover injury

Blahhhhhhhhhhh!!!

The work cover injury caused the fall, which in turn ended me in hospital for x days. I have fully recovered from the injuries I received from the fall, but I am still falling, I now use a walking frame or stick if I leave the house for any length of time, more for my own peace of mind, its humiliating falling over in a public place.

My insurer won’t budge on their decision and I am at my wits end.

Since [the fall] I have been unable to get any help or assistance from anyone related to my case. Everyone related to my case before and up to my last surgery in [date] has miraculously disappeared or been moved from my case.

My current case manager is the most ignorant, unethical, time wasting, unprofessional professional I have ever come across. I have a solicitor now, mainly because every time I spoke to her she would just throw her legal rights at me, and speak in “act blahblah blah of the blah blah code”.
I have received no payment for x months…

….based on the fact that she has to write to my Neurologist to request the information she requires, nothing more and nothing less. Yet its my fault because I haven’t provided the appropriate information to her. WTF.

I can’t provide the information, my insurer needs to request it in writing, as instructed to me by my GP and Neurosurgeon.

Meanwhile my whole family is struggling financially to the point where we are boarder lining on poverty. Amazing the difference a couple of hundred bucks can make to whether you eat or don’t eat.

Carefactor 0 kindly allowed us to publish her terrible story and wrote…

“…I need that moral support at the moment. Being a workcover victim on your own is a very lonely life. I want to be able to help others and maybe they can help me too”

Thank you so much for having the courage to share your story with us. And for opening up a discussion around this liability issue.

In fact this scenario is not uncommon!

worksafe-vic-does-not-careWorkcover insurance companies (and/or employers) will go to great length(and cost) to find the most pathetic “excuse” to deny (further) liability for a work related injury, or an aggravation or complication of an injury. Let’s face it, the reason why an employer (and/or an insurer) would dispute a workcover comp claim is very simple and boils down to a single five letter word: money.

Examples of injured workers cases we have heard of:

  • Injured worker underwent major shoulder surgery, which involved the harvesting and transplanting of hamstring (leg) tendons into the shoulder. Unfortunately the harvest of the hamstring tendons was complicated by a permanent (and not uncommon) permanent lesion of a nerve running closely to the harvest area, leaving the injured worker with severe burning pain in the leg (nerve lesion).  Not only did the insurer deny approval for diagnostic tests involving the leg (to affirm the nerve was severed and permanently damaged, and in the hope of finding a treatment, whether surgical or other), but the insurer went as far as to state “the [leg] injury has nothing to do with the work injury, therefore all liability is denied” (medical treatment and potential compensation by means of permanent impairment assessment). The injured worker ended up having to fight this decision at Conciliation, which referred the matter to  a Medical Panel. Of course the Panel found the insurer to be liable for the leg injury as it was a direct sequelae from the shoulder surgery. By denying liability for the – straight forward- leg injury, the insurer happily spent about $7500 (about $2500 for Conciliation incl. various medical reports) and a flat fee of $5000 for a Medical Panel opinion.
  • In another case, an injured worker was found to suffer from a bone infection in the original work injury (leg), following multiple surgeries. Specialised scans proved there was osteomyelitis (infection) in the bone, which needed emergency surgery (infections can spread and get blood borne and may end up fatal if untreated). At the time of the investigations for the infection, the injured worker has also developed swelling and redness in the same limb’s toe. Because of the serious risk that bone infections can spread to other parts (in this case possibly the toes), the injured worker’s surgeon had requested the toe be x-rayed to ensure it was not infected. The insurer not only denied the x-ray, but went as far as to state that the toe had caused the leg (joint) infection! Even though specialised scans showed only infection in the leg (site of original injury)! The insurer subsequently denied emergency surgery to the injured worker, even though the surgeon had explained at nausea how the toe may be connected to the leg re infection (spread). The insurer, in this case a psychopathic, uneducated, non-medically trained case manager endangered the life of the injured worker by denying surgery…even though it turned out the injured worker’s toe swelling and redness was a case of a simple chill blain! The case manager also denied any further medical investigations and treatment for the leg (original injury), ceased taxi transport, home help and was about to cease weekly pay when various IMEs and a lawyer’s letter set “things straight”.
  • In yet another injured worker’s case, the injured worker underwent leg and arm surgery following a terrible work accident. He was subsequently discharged from hospital with his freshly operated arm in a sling and on 1 crutch for his broken leg (operated on). A few weeks post-op the injured worker stumbled at a park and, although his arm was still in the sling, the stumble caused his arm to move abruptly, causing him a great deal of pain. The surgeon wanted to proceed with an urgent x-ray and ultrasound of the arm, based on a suspicion that a screw may have loosened because of the abrupt movement during the stumble. Again, the insurer denied the x-rays and ultrasound, stating the “stumble” was the cause of the injured worker’s problem now. This case was very quickly resolved with a substantial medical report sent to the insurer by the treating surgeon, arguing that the injury (or aggravation) was still work-related given that the injured worker would not have stumbled if he had not been operated on both limbs and shuffling around on 1 crutch and with an arm in the sling. In the end there was also no functional/anatomical damage to the arm (proven by x-rays and US), but merely a bruising.
  • Another injured worker told us his incredible ordeal with the insurer following a severe psychiatric injury suffered at work. While the insurer had accepted liability for the man’s psych injury, they rapidly denied him his weekly payments (and everything else) based on some surveillance, which showed the injured worker ‘enjoying a footy match”. They argued that the injured worker could not possibly be psych ill given he could go to the footy match! In the end the injured workers treating psychiatrist and psychologist put forward a comprehensive medical report stating they had specifically asked the injured man to “get out of the house” and undertake some “activities” to help him with his severe depression and extreme anxiety. Attending a footy match was part of that treatment. Conciliation rapidly overturned the insurer’s decision to cut him off workcover!

So, basically, this all means that if you receive a notice that your workcover claim has been denied, ask you treating doctors to immediately call or (preferably) write to your workcover insurance carrier. If this doesn’t solve the problem,  request a conciliation hearing to appeal the decision.  The Conciliator may be able to resolve the dispute provided you supply ample medical reports/letters from your treaters; or may refer you to a Medical Panel, or issue you with a certificate of genuine dispute, so you can take the matter to  court.(for more info about conciliation, medical panels etc see our frequently asked questions re WorkSafe Vic). Needless to say that we highly recommend you hire a workcover lawyer!

 

The bottom line is this: injured workers who have their claims denied should fight the insurance company, preferably with the help of a lawyer. Whether or not the insurer or employer believes that the worker is legitimately injured will turn out to be irrelevant, and the worker shouldn’t worry about whether the insurer or employer holds the injured worker in contempt. It is the injured worker’s right to have paid time off work and medical treatment paid for.
It may be great if anyone could share their own experiences with a related dispute, as to help Carefator 0 and other injured workers facing a similar situation.

We also suggest it may be a good idea to collectively start digging into workover (VIC) legal cases involving such matter.

 

[Post dictated by Workcovervictim but manually transcribed and inserted on behalf of Workcovervictim]

 

 

 

6 Responses to “Injured worker aggravates work injury after fall at home – weekly pay ceased!”

  1. Honestly these people must be robots to treat injured workers so badly. Dont the have a conscience? its just so ridicilous the way they treat people and that they are allowed to get away with it. I am so sorry for what you went through Carefactor 0 and I hope you get the help you need to get your payments reimbursed. Stay strong and keep in touch for our moral support. I wish we could do more to help everyone that comes to this site.

    • Thanks Pugsley, I am glad I have finely found a place that might feel a bit more like home. I have found the past 2-3 years a very lonely place. It helps just knowing there are people struggling with similiar situations that understand. If I had one wish it would be to take all our pain and suffering away, every single one of us.

  2. The following information may be useful – “altering, reducing or terminating weekly payments” by workcover VIC, from the online claims manual (section entitlements > weekly payments)

    9.6 – Altering, reducing or terminating weekly payments

    Under the Act agents can:

    ·         alter

    ·         not increase or not pay

    ·         reduce

    ·         suspend

    ·         cease

    or

    ·         terminate

    a worker’s weekly payments if the worker’s entitlement changes.

    Agents can terminate or alter weekly payments

    If the worker’s entitlement changes, agents may:

    ·         terminate or cease weekly payments

    ·         alter the basis on which the amount of weekly payments is calculated or choose not to alter weekly payments

    ·         not increase or not pay weekly payments in some circumstances

    ·         suspend weekly payments for the time that the worker is not eligible

    ·         increase or reduce weekly payments.

    Act ref:

    S114, S114(2), S114(2A)

    Written notice and period of notice required to terminate or alter weekly payments

    Unless stated otherwise, if agents suspend, terminate or alter a worker’s weekly payments it will generally only have effect:

    ·         if written notice is given

    ·         after the expiry of the required notice period.

    Act ref:

    S114

    See: 9.10.2.4 – Exceptions to notice required for exceptions to when a notice is not required under the Act.

    Agents to notify worker of rights to conciliation or review

    Workers are entitled to know the reasons for the decisions made about their weekly payments and have the right to seek internal review, conciliation or external review when they think a decision is wrong.

    Agents are to inform workers of their right to apply for conciliation or review.

    ‘External review’ means review by a Court being either the Magistrates’ or County Court.

    See also: 17.3 – Magistrates’ Court and County Court

    Act ref:

    S93CA(6), S93CD(3), S109(2), S110(2), S123A

    9.10 – Terminating weekly payments

    In addition to the termination of weekly payments after the expiry of the second entitlement period, weekly payments can be terminated for the reasons outlined in this section.

    However, it should be noted that a worker’s weekly payments are not to be terminated solely on the ground that the worker has returned to full-time work.

    Workers can recover compensation if their payments have been wrongfully terminated – see: 9.10.1 – Recovery for wrongful termination.

    Termination due to non‑entitlement

    The worker is not entitled to compensation.

    Act ref:

    S114(2)(b)(i)

    The agent had accepted liability but the worker was not entitled to compensation because the:

    ·         worker’s employment was not connected with the State of Victoria

    ·         worker was not a worker within the meaning of the Act

    ·         injury did not arise out of or in the course of employment

    ·         worker did not suffer an injury

    ·         worker suffered a mental injury to which s82(2A) applies

    ·         worker’s employment was not a significant contributing factor to the injury as required under s82 of the Act

    ·         injury was self-inflicted or due to serious and wilful misconduct

    ·         worker has made a false or misleading disclosure

    ·         worker has failed to disclose a pre-existing condition at the time of employment if requested in writing by the employer to do so from 1 July 1998 onwards

    ·         injury was caused by a transport accident and the worker has been convicted or found guilty of a serious road traffic offence in relation to the driving of the motor vehicle.

    See: 5.1.6.4 – Driving offences

    Act ref:

    S80(1), S82, S82C

    Terminate because worker is no longer entitled to weekly payments

    The worker:

    ·         is not or is no longer entitled to weekly payments because the worker:

             is not or is no longer incapacitated for work

             has an incapacity for work but it does not result from nor is it materially contributed to by the injury for which liability was accepted

             is breaching their RTW obligations

    ·         suffered an injury which was a temporary aggravation of an underlying or non-work related condition, the effects of the aggravation have ceased and the underlying condition is the cause of the incapacity.

    Act ref:

    S93, S114(2)(b)(ii), S200, S201, S202, S203, S204, S205

    Termination due to fraud

    The worker fraudulently obtained payments.

    Act ref:

    S114(3)

    workcovervictim3 May 10, 2013 at 11:44 am
    • Thanks for this it is somewhat helpful in my situation, but not sure where I go from here waiting on some advice.

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      • @carefactor0 – something similar happened to me. I had a bad injury to my knee for which I had 3 surgeries but they were not successful and I am waiting for a total knee replacement. When I fell at home, getting out of the car, I landed on my bad knee and it caused bruising and swelling, it was so painful I ended up at the emergency hospital. Thankfully no visible damage was done to the recent surgery, however workcover ceased my weekly pay alleging that my knee injury was caused by my fall. My surgeon was horrified. I took the matter to conciliation within the required 60 days time frame and sought additional medical reports from all my treaters, incl the doctors who treated me at the emergency department, I also obtained copies of the xrays etc they took. At conciliation the conciliator was satisfied however still decided to refer the matter to a medical panel as the insurance rep refused to budge. The panel found my fall had caused temporary aggravation of my knee with internal bruising however ruled that the aggravation had since healed and that my ongoing knee injury is truly due to the original work injury. Don’t let them (insurer) get away with it, they’ll try anything on. Medical Panels are not stupid and most see through the insurance scams, in fact they were bewildered. I had my weekly pay reinstated and back paid as well. I used workcover assist who are really very good and I recommend you engage them for your conciliation. Make sure you get as many medical reports as possible (the insurer pays for them), simply ask/write to your treating doctors and ask, explaining that the report will be paid for in full by your insurer. Ask them to answer specific question – i.e. has your fall which caused bruising etc now healed and is your current condition related to your initial work injury. Workcover assist will be able to help you with that.

        Just make sure you file for conciliation asap, as there is a time limit of 60 days after you have received the written notice that your weekly pay ceased (+ reason why).

        Good luck, you will win – it’s just a protracted fight but you will get there.