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).

 

Somewhat related articles

  Subscribe  
Notify of
Woowoo
Guest

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,

Complaint maker
Guest
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… Read more »
Woowoo
Guest
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… Read more »
FU_CGU
Guest

@Woowoo,

Apparently we all are scum 🙂 – welcome to WorkCover 🙂

Woowoo
Guest

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).

FU_CGU
Guest
@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… Read more »
Woowoo
Guest
@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”… Read more »