Workcover insurers willfully obstruct care to injured workers

medical-care-obstructed-by-workcover

Workcover insurance agents and their case managers routinely and wrongfully deny, delay and dispute legitimate workcover claims. One of the common techniques used is to stall and delay the claim-or a benefit-  as long as possible, preventing the injured worker from getting appropriate and timely medical treatment.

Our workers’ compensation system provides that you are entitled to all (medical) care reasonably required to cure or relieve from the effects of your work-related injury. But did you know that the insurer can -and often will -modify, delay, or even deny your doctor’s and specialist’s diagnostic or medical treatment recommendation(s)?

Workcover insurers willfully obstruct care to injured workers

medical-care-obstructed-by-workcover

It unsettles and disturbs me greatly when I witness – again- blatant and willful obstruction of medical (and like) care in the management of injured workers.

Workcover insurance companies are supposed to investigate, evaluate each any every claim fairly, and to promptly accept legitimate claims and begin providing the benefits including medical care and wage loss.

However, ‘substandard’ insurance industry practices are common place in Australia’s workcover claims handling

The types of such substandard appalling practices we frequently hear include:

  •  First denying the claim and then hiring biased experts (i.e. IMEs) to support the denial
  • Repeatedly using the same biased experts to deny or devalue/downgrade claims (Just look at our Karma bus page and you will see that injured workers are sent to the same known hired guns over and over again)
  • Withholding or delaying medical benefits despite the well documented need for care and treatment
  • Refusing to reconsider the denial of care after the injured worker or his doctor /specialist provide additional proof supporting the reasonableness and necessity of the treatment
  • Failing to make or stopping benefits such as weekly payments with no valid reason
  • Withholding weekly pay, to the point that injured worker is financially stressed, pawning personal possessions, losing his/her home and is subject to debt collections
  • Filing appeals (or disputes) with no likelihood of success in order to delay and gain ‘advantage’, or shall we say ‘leverage’
  • Creating pressure on the injured worker by delaying and denying benefits, and then making low-ball settlement offers, or insisting on unreasonable settlement agreements (with dodgy deeds of release)

Unlike in more civilised countries such as Canada and USA, when these workcover insurance companies unfairly delay or deny benefits, they do NOT run the risk of having to pay the injured worker additional damages for bad faith delay of payment.

Why do workcover insurance agents (and employers) try to prevent an injured worker from seeking medical care?

The simple and shortest answer is MONEY! The employer and/or its workcover insurance agent can and will seek to delay medical care to frustrate the injured worker from bringing or pursuing a workcover claim.The stall and delay tactics can be and are being used both by the employers and their insurance company to prevent the injured worker from obtaining necessary, timely medical care which is causally related to his or her work injury.
The employer and/or their insurance company can and do hope that only with the delay of time that the injured worker could or may be involved in an intervening accident or injury (one that occurs between the event(s)) which potentially could cut off the liability of the employer and/or their workcover insurance agent.
If an injured worker delays or waits for medical care, the employer or its insurer may also turn around and deny approval for medical care at a later date, citing that the injured worker has simply waited too long.

Among the many duties of a workcover case manager, and certainly that of the nurse case manager, is to ensure that the injured worker complies with (medical) care and to determine whether s/he is improving because of that care.

Among the many duties of a workcover insurance case manager is to be certain that the injured worker is referred to competent health care practitioners in a timely fashion, that quality of care is delivered, and that there is tracking of the appropriateness of the care to the specific injury.

But, in the absence of a personal relationship with an injured worker, a seasoned case manager can become distrustful of injured workers in general and very protective of insurance $$$ resources. They feel justified in this response, having been “fooled” by 1 or 2 (injured) sods in the past, and if this ingrained enough, they will simply distrust all injured workers until proven otherwise… and then some.

They may delay sending weekly pay, including mileage, but more importantly, deny approval of needed, medical and like care. This delay or denial will vary from questioning why a doctor ordered a medication, surgery or a diagnostic procedure, to questioning the relevance of a requested referral.

As control by the (medically uneducated) case manager tightens, the resistance and resentment felt by the injured worker increases, and often, subjective complaints worsen due to the anger and frustration due to feeling obstructed and victimised!

The question then becomes: “How do you remedy a situation in which a newly injured worker is inadvertently punished for the occasional misdeeds of workers who have gone before?
“Why is it not criminal in Australia when workcover insurance companies injure, disable and even kill injured workers through delaying and denying medical care?”

We strongly believe  that a workcover insurer must treat injured workers fairly, rather than simply focusing on profits and services to employers (their customers).

 

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7 Responses to “Workcover insurers willfully obstruct care to injured workers”

  1. This is like de ja vue… I myself have been having treatment delayed, but I will say when I called my case manager she has done her best to get me into to see the IME much earlier than originally advised, instead of having to wait 2 months my appointment has moved up to a week away. This is still delaying my procedure and I am now off work for a fortnight to see if the pain improves before the procedure goes ahead, (pending approval of course).

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    • @Woowoo,

      Mmmmmmm ……. a case manager doing an injured sod a favour? There has to be a first time!

      I don’t know how far you are into you claim Woowoo, but seeing an insurer IME is only designed to screw you. I supposed, if you know you are going to get screwed – might as well get it over and done with now rather than wait around.

      Depending on the IME, there is a good chance their report will come back with “a pre-existing degenerative condition” or “I could find no problems with Woowoo and nothing that would prevent Woowoo from returning to full time duties”

      I used to be an optimist, but several years battling the corruption and lies associated with WorkCover and their associates, I am a tad pessimistic – particularly regarding Workers Compensation Insurers!

      Good luck (you are going to need it) 🙂

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      • @FU-CGU
        Bit of “tongue in cheek”… the favour being the appointment being brought forward 6 weeks… This process has already been 7 weeks in the making, The procedure needs to be done to enable me to work. I am now off work, as I can’t work with headaches that bad. If you could see how many typo’s I do and correct prior to posting you would never believe I was a proficient data entry person prior to the accident.

        She is another”new case manager” although I am yet to be informed of this.

        Understand I need a lot of “luck” and thankyou

        😉

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  2. I am also as pessimistic as FU_CGU.
    The issue is more why your own treating doctor’s opinion or specialist’s opinion is not good enough and how an IME who will examine you for an hour or less will be more qualified to give an opinion than those treating you?

    In many cases the IME is not even a specialist in the area of your injury. You would be better off asking your case manager why they think the information from your treating specialist is not good enough and remind the case manager you are now worse due to lack of treatment and that you want approval to see a treating specialist of your own choosing for a second opinion and ask for a reason why they will not approve that.

    Find out the qualifications of the IME and if they do not treat people with your type of injury make an objection in writing ASAP before you see them, stating that.
    Regardless go ahead and get an appointment with a real treating specialist for a second opinion on your injury under Medicare. Make sure you take all your own treatment evidence and imaging studies reports and provide copies to the IME and say that you want it stated in the report you provided such evidence as in my case and others I know of, the IME received a limited, biased selection from the insurer.

    As FU_CGU advises, there is a good chance the IME will be one of the “preferred” insurer IMEs and there is a reason for this, so look forward to having your treatment and claim denied based on the report. If we are right then you will need your own medical evidence to use to dispute the insurer in any case so get your own second opinion now.

    My case manager, and I might add she had always been very good, sent me to a so called “independent” physiotherapist on the basis he was meant to help co-ordinate my treatment because I had a physical and a psych claim and my psych health was impacting on my ability to manage my physical injury. Her referral even stated this and she was equally shocked when the IPC determined I had no impact from my psychological injury so my physiotherapy should be denied- WTF!
    When my case manager tried to support me her supervisor took her off my case in a big hurry and then she suddenly didn’t work for the insurer any more. Then the insurer then denied my claim for about $1500 per year of physiotherapy treatment on the basis of a very obviously fraudulent report and were prepared to spend around $20000 to defend the whole matter at the WCC. It took me a ton of complaints and about two years before the insurer approved me to see a real treating specialist and then they overturned the decision and gave back my treatment!!

    The real issue is they are all so used to carrying on this way they forget it usually costs less just to give someone the treatment they need so they can get back to work.
    The only winners are the IMEs and the insurer’s solicitors who back it all because the longer it goes on the higher the uplift in costs for them.

    I have found there are two types of case managers- those who are just innocent, dumb pawns in the game or the vicious bullies who are just there because they love the power when they destroy injured worker’s lives. In my experience of around 15 case managers, the innocent one’s usually leave once they wake up to it all but the long stayers just stick in there aiding and abetting the insurer and/or their solicitors in denying claims and causing disputes. There are bonuses for getting injured workers off WC and there is the bonus of feeling all-powerful if you are inclined that way.

    Perhaps the case managers and their supervisors should be sent to some of the psychiatric IMEs for a personality assessment!! It would be more effective if it was a requirement they were sent to the IME in the place of the injured worker with all the information as though they were the injured worker so they can find out for themselves!!!

    Depending on the state you are in there are various guidelines that are applicable so it is really important to get onto your state WorkCover website to read the IME guidelines and also find anything regarding reasonably necessary treatment.
    After your IME you should compare the IME report with all your treatment reports as you can often find there are contradictions between the diagnoses and between what is on imaging study reports and what the IME records was reported. There are often contradictions within the report itself.
    If you do get a bad IME you can challenge the report if you can point out inconsistencies and if you can provide your own medical evidence to support your need for treatment. Then you put it all in a complaint to the insurer and WorkCover and ask for the IME report to be removed if it appears to be fraudulent!!

    I hope you are one of the lucky ones and you get a good IME who will support you but be prepared just in case!!!

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    Complaint maker March 15, 2014 at 9:51 am
    • I have been to see the same IME 8 months ago.
      Report was favourable in part…

      I do read the reports and highlight discrepancies, I also have appointments to see my solicitor after each report.

      My requesting Dr is apparently quite high in his field, and has frequent dealings with Work Safe and TAC, so I feel confident the procedure will go ahead and if not, then I don’t work and a further claim for wages will proceed….

      I know there will be a fight, They started it, I hope I can see it through, if not I lose everything I have worked for for the last 20+ years….
      Agree the case managers should be involved more in the face to face dealings… Some have been great but short lived.
      Its so wrong everyone is treated as a scammer just because some do doesn’t mean everyone needs to be treated as scum…

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  3. I had my appointment today… He is one of the “nicer” ones.
    I will wait to see his report, but he asked repeatedly if I had seen a specialist about my injury.
    My GP hasn’t referred me and so I asked if I should request a referral, The IME was quite adamant I should see one…. His notes were interesting,

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