WorkSafe: complex claims process needs fixing
Victoria’s workcover scheme must be fixed to ensure that complex claims are resolved in a fair and timely manner, a Victorian Ombudsman investigation has found.
Tabling the Investigation into the management of complex workers compensation claims and WorkSafe oversight today (12 Sept 16), Victorian Ombudsman Deborah Glass said that while the workers compensation scheme is operating well in the vast majority of cases, the current system fails some particularly vulnerable people.
“The overall system is not broken, but the problems we identified in complex cases – some 20 per cent of the overall claims – go beyond a few isolated examples of bad behaviour. They cannot simply be explained away as a few bad apples spoiling the barrel,” said Ms Glass.
WorkSafe underwrites the Victorian workers compensation scheme with claims management functions outsourced to private insurers. During the investigation period the agent insurers for Worksafe were Allianz, CGU, Gallagher Bassett, Xchanging and QBE. The system currently incorporates a series of financial incentives for agents, including when claims are terminated or workers return to employment.
The investigation examined complex and often extended claims across different industries, roles and injuries (both mental and physical) to assess whether:
- agents unreasonably denied liability or terminated claims
- agents took such actions in order to obtain financial rewards available under the contract with Worksafe
- Worksafe provides effective oversight of the agents and their claims management processes.
Key recommendations from the investigation call for a review of dispute resolution processes within the system and improvements in oversight of complex claims by WorkSafe.
“We found agents cherry-picking evidence to support a decision to reject or terminate a claim – as little as one line in a medical report – while disregarding overwhelming evidence to the contrary. We found Independent Medical Examiners (IMEs) – whose opinions agents use to support their decision making on compensation – receiving selective, incomplete or inaccurate information. We also saw evidence of decisions being influenced by financial incentives to terminate claims.
“In effect, we found cases in which agents were working the system to delay and deny seriously injured workers the financial compensation to which they were entitled – and which they eventually received if they had the support, stamina and means to pursue their cases through the dispute process,” said Ms Glass.
The investigation attracted significant public interest after it was launched, with dozens of workers and others involved in the system contacting the Victorian Ombudsman to offer assistance or make submissions.
The investigation involved detailed reviews of claims across all five agents. A random sample of agent email records was examined and interviews conducted with injured workers and their families, executives from the five agents and former agent staff. Stakeholders including the Accident Compensation Conciliation Service, the Australian Medical Association, the Police Association of Victoria and the Community and Public Sector Union made submissions.
“Action must be taken to address the complex end of the system where terminations are rewarded. WorkSafe needs to examine its incentives – and the use of IMEs – to ensure the system rewards sustainable decisions and to target its oversight accordingly. The process for resolving disputes also demands careful reconsideration – it is in the interests of workers, employers and the public at large that the resolution of claims should be both timely and fair.
“WorkSafe has begun addressing many of these issues, and we have already seen improvements since my investigation began in 2015, but this work must go on. The cases we investigated are not merely files, numbers or claims; they involved people’s lives, and the human cost should never be forgotten,” said Ms Glass.
Investigation into the management of complex workers compensation claims and WorkSafe oversight
Workers’ compensation failing complex patients, needs fixing, Victorian Ombudsman finds
Victoria’s workers’ compensation system is failing vulnerable and injured people and needs to be fixed, a Victorian Ombudsman’s investigation has found.
Ombudsman Deborah Glass said complex cases, which make up 20 per cent of all WorkCover insurance cases, were being mishandled, deliberately delayed, or cancelled with minimal medical reasoning.
The report was also critical of WorkSafe’s use of financial incentives that rewards agents for terminating compensation, saying it distorted the system.
“This affects people’s lives and the human side of this shouldn’t be forgotten,” Ms Glass said.
The investigation, sparked by 500 complaints about WorkSafe and its agents in 2014–2015, looked into the management of 65 complex compensation claims by WorkSafe’s agents, including major insurance firms Gallagher Bassett Services, QBE and Allianz.
“We found cases in which agents were working the system to delay and deny seriously injured workers the financial compensation they were entitled,” she said.
Ms Glass said some agents had been cherry-picking evidence to reject claims, using as little as one line in a medical report.
She said independent medical examiners (IMEs) were being used to support WorkSafe agents’ decision-making including people described by agents as “good for terminations”.
“The impact of this on vulnerable people cannot be overstated,” she said.
Common WorkCover problems:
- Regularly changing case managers, resulting in multiple requests for same documents
- Delays in making decisions on claims and approvals
- Sending clients to multiple IMEs until one disagrees with claim
- Withdrawing entitlements regularly, forcing clients to seek legal representation to get reinstated
- Suggesting that something in the client’s background is responsible for their condition
“The cessation of payments — for up to two years before a case is concluded — will inevitably lead to financial hardship.”
The ombudsman’s report said 75 per cent of 130-week termination decisions were overturned by the courts, was evidence of unfair treatment.
Ms Glass made 17 recommendations to the Victorian Government, including a review of the dispute resolution process, and improvements in the oversight of complex cases by WorkSafe.
In its response to the ombudsman, Worksafe Victoria said it would do “everything it could” to improve.
“WorkSafe acknowledges the report highlights a number of cases in which injured workers were not given the support and respect that all injured workers deserve,” chief executive Clare Amies said in a statement.
“It also found instances of conduct which were totally unacceptable.”
The Insurance Council of Australia also said it would review the findings in the report.
Claims process ended in suicide: ombudsman case study
In one case, an injured worker took her own life during a long drawn-out claim with WorkSafe insurer CGU for a psychological condition that developed after she had been sexually harassed and assaulted by her boss.
CGU initially rejected the claim, but a magistrate later found “serious sexual misconduct and harassment” had the worker had sustained a work-related injury requiring treatment.
Over the next few years, the Ombudsman said CGU sent the worker to numerous independent medical examiners and later cancelled her cover.
CGU reinstated the worker’s entitlements shortly after the woman had killed herself.
Former police sergeant Ron Fenton also said his dealings with a Worksafe insurer left him on the verge of suicide.
For seven years, Mr Fenton has been involved in a bitter stoush with insurer Gallagher Bassett (GB), after his 40-year career with Victoria Police left him with 37 bullet fragments in his head and PTSD.
“Gallagher Bassett basically started treating me like I was a criminal and consistently made life more and more difficult questioning everything I did,” Mr Fenton said.
Mr Fenton was injured in 1984 when his police car was sprayed with bullets after he intercepted a gunman who had murdered a security guard in Clayton.
He was left with partial paralysis down his right side, then 18 years later, after he was threatened by another criminal, his mental health deteriorated.
When he was late for a regular doctor’s appointment, his cover was cut off and only reinstated after he took GB to the Accident Compensation Conciliation Service.
Mr Fenton was also sent to numerous IMEs, most recently over a claim for total impairment cover.
“I had one that said I was severely impaired. I went to another one said I was severely impaired. So when I went for an impairment claim — they sent me to another one and ‘he said oh no, he is not impaired’,” he said.
His claim was rejected on the basis of the third assessment.
“It is dehumanising. It makes you feel like a criminal it makes you not want to actually claim.”
Som related contect within the oublic domain:
Nick McKenzie and Richard Baker report in The Age on 26 December 2013 how WorkSafe prefers spending its money on lawyers defending workers’ claims rather than injured workers’ entitlements. No surprises there…
Here’s the transcript of the article
Here’s a recent article from The Age’s Nick Toscano about the treatment meted out to injured workers by Worksafe. These tales are unfortunately corroborated by the majority of my clients. If you are unsure about your rights as an injured worker, seek legal advice from an accredited specialist. See: http://www.theage.com.au/victoria/workcover-hurts-rather-than-helps-the-injured-report-20140822-107f8u.html#ixzz3E70ZGLSy
Here is an article by Benjamin Preiss from The Age of 11 September 2016. The Ombudsman has investigated the WorkCover Insurers’ practices and she was less than impressed.
Here is the link to the original article in The Age: