The dirty trick of the paper-based & in house review of your workcover claim


Aside from independent medical examinations with hired guns, the biggest and most pathetic threat to injured workers is that the workcover insurer can pull what we believe is a dirty-yet legal-trick and send your workcover claim (file) for what is called a paper-based review or an in-house medical review.

The dirty trick of the paper-based & in house review of your workcover claim

A Paper-based-claim file review or in-house medical review is a review by an insurance ‘doctor’, based on questions posed by your (medically uneducated) case manager, and you, the injured worker are not (necessarily) informed that this process is taking place.

If you get hurt or made ill while working, you are entitled to see a doctor of your own choosing. The workcover insurance company has to is supposed to pay for all your reasonable and related medical care that your treating doctor(s) provides.

The workcover insurance company can and will also send you to an “independent” medical examination (IME). As we discussed in yesterday’s post, this is a doctor of their choosing who does not provide you with medical treatment, but instead is supposed to review your medical records, examines you (although some of them don’t do it for more than 10 minutes) and then writes a report about your condition, the treatment you need, whether your problems are related to your job duties, etc. A lot of these guys are hired guns, but at least they have to physically look at you before they try to mess with your life.

But, we believe they aren’t the only (and perhaps) biggest threat to you especially if you have or need long term medical care. The workcover insurance company can pull what we believe is a dirty, albeit ‘legal’, trick and send your file for what is called a paper-based file review or in-house medical review.

Unlike an IME, with a paper-based/in-house review, some insurance ‘doctor’ (aka ‘Medical Advisor) who has never seen you and never will, looks at your medical records and sight unseen determines if the medical care being suggested by your doctor is appropriate. It may even be an excuse to deny you a MRI. It could be the reason that they don’t approve the surgery that you so desperately need. Whatever the reason, it’s a total crock of you know what.

These “doctors” are in our opinion the ultimate hired guns. It’s a joke that it’s even allowed. The only saving grace is that everything they say is obviously nothing more than hearsay! In most cases these “opinions” can obviously be proven to not be as reliable as the doctor/specialist that has in person examined you multiple times. But unfortunately this often delays your care (and case).

Think about it, what doctors perform such “work” for insurance companies? These insurance doctors are definitely not standouts in the world of medicine but ‘doctors’ who for some reason or another (such as greed, poor performance and inability to get a job elsewhere, sanctioned doctors, retired doctors etc) have fell into the stable but dubious practice of working either salaried or at a flat rate per “review”  performed…. a pretty easy way for them to make a living, even though it comes at the expense of innocent injured workers.

The only way to counter these adverse “reviews”  is obviously with filing a dispute (i.e. Conciliation in VIC). But we’d be lying if I didn’t state that paper-based/in-house file reviews are a threat to you and your case. And, perhaps, the worst part is that they don’t have to tell you that they are doing it, so you don’t know about the results until the insurance company has an ‘opinion’ in their favour.