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
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!
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
- Some Signs Of Bad Faith Insurance Claims Settlement Practices
- Workcover insurance bad faith negotiation tactics
- Bad faith claim against workcover insurance company
- Unfair Claims Handling Practices in Workcover Insurance – No tortious Duty of Good Faith
- Workcover insurers should be paying claims, not bolstering profits