Tips to ensure your surgery is accepted by workcover

surgery-workcover

Many workcover victims ask us whether IMEs can prevent an injured worker (you) from getting recommended surgery. Unfortunately the answer is “yes” but the following tips may ensure you win the “battle of the medical opinions” and have your surgery approved by workcover.

Unless life-saving surgery, injured workers are often sent to an independent medical examination before their recommended surgery is approved by workcover.

You all know by now that an IME is a medical examination, undertaken by a doctor that the insurance company
sends you to, at their cost, to get an ‘independent’ medical opinion about the cause and/or treatment for your injury.

Unfortunately there is still often a “disagreement” about the recommended course of an injured worker’s treatment.

Tips to ensure your surgery is accepted by workcover

If your treating specialist recommends surgery, and you want to go through with the procedure, you basically hope for the best that the IME doctor will agree, but you should prepare for the possibility that the IME will not agree.

A few tips to help you win the battle of the “experts” and have your surgery covered

  1. First of all it is very important that you have a treating specialist who is very qualified in the field of your injury and who has a good reputation. If you suffer from a shoulder injury, ensure you are being treated by an orthopedic surgeon who specialises in ‘upper limb’ surgery (generally shoulder, elbow, wrist). The recommendation given by an ‘expert in the field’ will undoubtedly carry more weight than an opinion of for example a ‘general orthopedic surgeon’.
  2. This is important in the event your workcover insurance company sends you to an IME who specialises in the particular area your injury. So if your treating doctor does not have much experience in this type of procedure, or is a general surgeon rather than a specialist, then the recommendation may be given less weight.
  3. Credibility is also very important. The reputations of the doctors can sway the opinion one way or the other.
    Honestly, a lot of workcover insurance companies screw this part up by sending injured workers to “hired guns” that are known to say whatever needs to be said, not necessarily the truth.
  4. If your doctor/surgeon has the experience and expertise to give the opinion for surgery, be sure that s/he backs it up.There needs to be a rationale/explanation behind the decision for surgery, other than to say that, for example, if physio does not work then this surgical procedure should be tried. Your surgeon needs to give specific medical reasons why s/he thinks that this is the right procedure. This is so that a biased IME’s opinion that surgery is not necessary or ‘reasonable’ can be dismissed easier.

When you want to get your surgery covered, it can be a frustrating process to have to fight to have your opinion accepted. But with the right medical evidence and support (and with a good lawyer in your corner) you have a much greater chance at winning the “battle of the medical experts”.

Also remember that you can challenge any decision the insurer makes, by lodging a conciliation (VIC). Again, in order to ‘win’ your conciliation, it will be important to seek as many medical reports as possible in your favour (i.e. detailing why you would benefit from surgery). The more ‘credible’ your treating doctors are (and their reports) the easier it will be for you to prove the conciliator (or a medical panel) that you really need that recommended surgery.

You don’t need workcover’s approval to seek medical reports for a conciliation in VIC – simply ask your treating doctors (can be anyone (or all) who treats you from your physio to your pain specialist, psychiatrist and specialist surgeon) to write a report for the purpose of conciliation and ask them to bill your insurance company directly.



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5 Responses to “Tips to ensure your surgery is accepted by workcover”

  1. We recently had an issue with the Insurer insisting on an IME appointment. We found out that an IME appointment MAY ONLY be necessary where information about the issue in dispute cannot be resolved by information provided by the worker or their THP’s.

    From the VWA website: Medical reporting

    A Treating Medical Practitioner Report is used to obtain clinical information about an injured worker’s condition, as an ALTERNATIVE to arranging an Independent Medical Examination.

    The Agents are ignoring and abusing this requirement bc most of us are NOT aware of it and the old threat that if you don’t go to the IME appointment then they WILL terminate or suspend your entitlements is an extremely serious & powerful threat. Find out when they last sought up-to-date information BEFORE you allow them to organise and IME. They need to be specific about the medical & legal reasons why, which most of the time they aren’t and there is no real “issue” neediing to be clarified or resolved. Just the predictable, send u to one of their hired guns so they can say something that allows them to terminate your entitlements and then make you fight like hell bc of the collusion and corruption within the scheme.

    Just a question on your last paragragh – are you saying that reports can be obtained without seeking a Medical Authority Form from the ACCS? If so, is it on the basis that on the decision notice the Agent states that if a review of the decision is required then they will pay the reasonable costs?

    Thnx for your help.

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    • @Admin, from our own personal experience we have never sought formal approval from the insurer to pay for medical reports for a conciliation. It is implied they will once conciliation is filed. So simply ask your supporting treaters for a report (as many as you like) and ask them to bill workcover insurer. Period.

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      • @WCV, thnx that’s good to know. Just had a fight with the ACCS who wouldn’t authorise reports because they said the issue in dispute was not “medical” implying it was more of a technical dispute about the Law. Good to know what you’ve advised and won’t even ask for one next time. Amazing what they get away with. Thank God we have all joined up here.

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  2. Hi, I was attacked at work in 2011 and have hemifacial spasm and blepharospasms also a Ptosis of the right eye, thumb and neck problems and denied psych depression and anxiety. I have been assessed by Workcover qld system at 2%, have a union lawyer $58,000 to date and have been negotiating a settlement, now at stage of seeking a barrister and court procedures. There is very little support but any is welcome. CarolRN

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    • @Carol Ethell – I am so sorry to read about what happened at work and the situation you find yourself in. I don’t quite understand why you are in so much debt for lawyer fees, did you not sign up for a no win no fee agreement?
      As for psych injuries, the current laws are really very harsh in the sense that SECONDARY psychiatric/psychological injuries do NOT count for the purpose of permanent impairment. Only PRIMARY psych injuries are taken into account.This means that for example if the ‘attack’ was not extremely ‘traumatic’ (as in immediately following the incident) it is likely not to be deemed a primary psych injury. On the other hand lets say you had a gun put to your head, than it is most likely a psych injury (such as PTSD) would be deemed a primary psych injury.
      If you developed psych symptoms because of your injuries (and how you are treated by workcover etc) and how these affect your life, such as depression, then these psych injuries are deemed to be secondary and do not count towards permanent impairment.
      In the case of workcovervictim, also a nurse, she was viciously assaulted at work by a patient and suffered permanent serious injuries. She was sent to an IME for a ‘permanent impairment’ assessment for psychological injuries – namely PTSD, and ensuing major depression. The IME (biased) found that WCV only suffered 5% primary injury and 25% secondary psych injury. She appealed the decision at the Medical Panel (in VIC) and the assessment was reversed! She received around 23% primary injury and over 20% secondary psych injury. The primary psych injury counted towards her permanent impairment (WPI) although it is calculated through complex calculations (so hey did not simply add 23% but more than enough to have a overall (physical + psych) WPI of over 40% = serious injury). So it MAY be possible to obtain a more favourable decision on your primary psych injury (if any) but a lot depends of the evidence at hand, the precise circumstances of your incident, and whether or not you sough psych treatment straight after your injury. It’s a very complex matter and high risk as a decision can go either way in Court – and legal costs increase dramatically if you need to go to court (i.e. barrister fees, expert witnesses, medical reports etc).

      Additional reads

      http://aworkcovervictimsdiary.com/2011/09/impairment-benefits-for-psychiatric-impairment-how-to-achieve-the-maximum/
      http://aworkcovervictimsdiary.com/2012/11/injured-worker-not-entitled-to-lumpsum-for-secondary-psychological-injury/
      http://aworkcovervictimsdiary.com/2014/01/common-law-claims-psych-injury-injured-workers-often-fail-establish-breach-duty-care/
      http://aworkcovervictimsdiary.com/2014/06/workers-compensation-psychological-injury/
      http://aworkcovervictimsdiary.com/2014/09/ama-guides-impairment-rating-problematic/

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