Workcover insurers and their case managers can be master manipulators. They often use various delay tactics to wear you down, knowing that you need the money. They will also often delay or discourage or even out-rightly deny medical treatment that is needed.
Workcover insurers are master manipulators – stall tactics
Many people may not realise it, but despite the fact that insurance companies are offering coverage to handle emergencies and losses, these firms are actually in the business to earn money. As such, they learned long ago how to leverage situations so that they are able to delay and deny rightful claims.
Many insurers, including those of worker’s compensation, and their case managers attempt to use stall tactics in an attempt to frustrate the claimant/injured worker sufficiently to get away with not paying claims. In the legal world, when insurance companies refuse to pay or delay a valid claim unnecessarily, this is known as bad faith insurance.
Whilst we are by no means saying that all workcover insurance case managers are evil or unethical. Some are nice and empathetic to your situation. However they are being paid to do a good job for their employer and doing a good job means making a profit for the workcover insurance company. Making a profit for the workcover insurance company means getting —you the injured worker— to run or settle your workcover case for as little as possible.
Workcover insurances (and their case managers) use a wide range of
practices dirty tactics to prevent you from obtaining medical (and like) treatment and/or money for valid workcover claims. For example, these ‘practices’ may involve repeatedly lost paperwork by your case manager, sending you for unnecessary IME assessments or ignoring information from your own treating doctor(s) indicating you have a real and valid medical problem.
Many such workcover insurance companies will also often drag out the claims process in an attempt to avoid paying out a claim, which often puts injured workers in a position of having to cover expenses while waiting for a claim to be approved.
These dirty tactics can put you in a terrible situation. For example, if you have a medical claim that the workcover insurance company delays paying, you may be put in the position of covering all medical costs on your own—and dealing with the financial burden and possible debt—or eliminating vital medical help that you cannot afford, putting your health at risk. The consequences of these well-known tactics can be far-reaching, affect your finances, your quality of life and even your health.
You may face extreme financial challenges, including staggering medical expenses and a prolonged period of disability from employment. Workcover insurance companies count on this pressure and often use it as a strategic tool. The more desperate the injured victim becomes for income, the more likely that victim is to accept a low-ball offer, or ‘walk away’.
Top workcover insurer Stall tactics
Below are some of the frequent tactics that workcover insurance companies use that interfere with rightful workcover claims.
1. Demand “More Information”
To stall the actual delivery of care, workcover insurers hold out an insincere promise to authorise/approve payment if the injured worker’s doctor provides more information. This leads the doctor on indefinitely, while case managers never say absolutely “no” until the injured worker gives up (or dies!). Doctors agonise over having to choose whether to wait one more day for approval or to go ahead with , for example, the needed surgery (or even an urgent MRI/test) and potentially damn the injured worker, his family to assuming the financial consequences. If they do go ahead without approval, no one rescues the bankrupted injured workers and their families! (the other option is, of course, to have the treatment at a Public Hospital, and in doing so the cost is shifted onto the tax payers and not the insurance)
Delaying payment unreasonably while insisting that they are investigating medical records is also part of the demand ‘for more information’ and a very common stall tactic. When worker’s compensation insurance pays slowly, in part, or in some cases, not at all, these companies are able to rake in profits that they are not lawfully entitled to.
2. The “Expert” review
An expert is a doctor who did a procedure or took care of a similar patient (or injured worker) this week. Workcover insurers define any has-been, retired, octogenarian, unemployed, failure with a medical license an expert, paid to deny care. This is practicing medicine without examining the injured worker or seeing all the data/evidence. In effect, the “licensed” nurse or doctor working for a workcover insurer is, in our injured opinion, practicing medicine unprofessionally and criminally.
3. Call a procedure “Experimental”
Workcover insurances and their case manager appear to be able to claim the right to define what is experimental.
A procedure should not be considered experimental if the statistical outcome is known, or even if others have already reported the procedure.Case managers love for example denying pain relieving procedures such as nerve blocks, pain stimulators etc, and will often refer to such a procedure as “experimental” to get away with it!
Other bad faith workcover insurance tactics
Among bad faith workcover insurance tactics:
- Extensively search an injured worker’s medical history to find details in an effort to allege that a pre-existing condition is actually the cause of a work injury or illness
- Send injured workers to doctors that they pay to be biased in a workcover insurance favour
- Set unnecessary hearings (i.e. disputes such as Conciliation, etc) that delay payments, making injured workers vulnerable and further complicate their injuries.
- Have private investigators follow and watch injured workers in hopes of alleging that the injured worker was not actually hurt while working, or that they are not as incapacitated as they state
- Begin a fraud investigation needlessly— more common than you think!
- Bring fraud charges against an injured worker, this can be done via surveillance showing some ‘more activity’, but the injured worker will often be accused of fraud (and denied benefits) before proven innocent!
- These tactics are used by worker’s compensation insurers not only to deny claims, but to make it so frustrating for injured workers that they may harm themselves by working when they clearly should not be
- Failing to pay a claim in a timely manner
- Offering a settlement amount below what the injured worker is entitled to
- Using an injured worker’s previous (unrelated) claims as grounds to deny a new claim
- Failing to conduct a reasonable and full investigation of the claim
- Misrepresenting important facts
- Misuse of injured workers’ medical records
- Requiring excessive paperwork
- Purposely targeting high-cost claims for denials
- Ignoring expert opinion in cases where that opinion would result in a claim being paid out (such as finding that a death was suicide when a medical examiner has ruled it accidental)
Remedies for Bad Faith Worker’s Compensation
Worker’s compensation insurance violations of state laws in more civilised countries often give rise to bad faith claims, as well as constructive fraud against insurance companies. By definition, this is considered an unfair and deceptive insurance practice. Unfortunately in Australia workcover insurers are exempt to act in “good faith”! More on that in our next article.
Any injured worker who finds that their workcover claim is being stalled, delayed or has been denied should complain to their workcover insurer and workcover authority and immediately seek the assistance of a competent and experienced worker’s compensation lawyer who represents only injured workers.
[Post dictated by WorkcoverVictim and manually transcribed on her behalf]