WorkSafe VIC – complex claims process needs fixing

ombudsman

Further to a recent comment made b y “Tom”,  here is the press release from the Ombudsman about its investigation into Victoria’s workers’ compensation scheme. We knon it is well overdue as it occurred in 2016 but here it is. Nothing we did not alteady know as injured workers on the system. Let’s hope things have improved?

 

WorkSafe: complex claims process needs fixing

September 2016

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

Update added

Workers’ compensation failing complex patients, needs fixing, Victorian Ombudsman finds

Updated

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:

WorkSafe pays law firms bonuses to minimise victims’ payouts

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

WorkCover hurts rather than helps the injured: report

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

WorkSafe system failing ‘particularly vulnerable people’: Ombudsman

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:

http://www.theage.com.au/victoria/worksafe-system-failing-particularly-vulnerable-people-ombudsman-20160912-gre7li.html

5 Responses to “WorkSafe VIC – complex claims process needs fixing”

  1. I’m located in Sydney. In late 2014 ( days before Christmas ), i was working at a company and had my foot crushed against a pallet, by the rear end ( i believe ) of a forklift. From this accident i sustained mid foot fractures and spent over a month in hospital. The forklift driver apparently didn’t see me, as i was wrapping a load on a chep pallet and i believe this was definitely negligence. While in hospital i contracted with a solicitor ( on a no win , no fee agreement ) . My solicitor seems to have “drawn” out the whole litigation process. The “others” ( employers, insurers ) refused to settle and a “statement of claim” has been processed/finalized ( really not interested in going to court, to be honest ) the “others” lawyers have requested for me to have another medical assessment ( already had some in the past, requested by my legal representatives ) . I have considered contacting the solicitor/s i contracted with, and canceling the proceedings/case, as my foot has healed quite well actually ( I could develop arthritis in the future, but may not live that long to experience that anyway ). I have less than around $30,000 total in savings, in financial capital, and have not been employed now for well over a year. So my cash savings is lessening more and more, and if i lose the case, i can imagine the costs to me will be very unpleasant to say the least ( possibility of having to pay the “others” legal bills ) . I was employed as a contract employee through a recruitment agency, at the time i sustained the foot injury, and continued working as a candidate for the employment agency up until march 2017, then stopped actively working for them, because of certain incidents, among other reasons, that had me question if unpleasant experiences while employed were because i’d started legal action against the “others”, but could not prove if this was so. I have plenty to do at home anyway ( unfinished projects ), and don’t like to feel “boxed in” by seeking employment in a hurry, just to appeal to solicitors, in regards to my character ( think work ethic ).The fact i have not been legally employed for over a whole year, certainly does not help my case or give me expectation of court case success, hence why i have considered asking my legal representative what his financial charge will be if i end the proceedings altogether, and just pay him his dues. Even if i go to court and succeed in a victory, the remuneration would not be that much ( i think ) especially after paying the solicitor fees and administration costs. In the meantime i have quite a few material possessions to sell off, to gain me money. The stress of going to employed work, then coming home to see much else that needed tending to around the house was quite unpleasant, so i can actually do with not being employed at the moment. Have a fatherless nephew with heath problems and learning disabilities also. What would your advice be ?

    appreciate your opinion.

    Thanks,
    John

    • @John, as far as I understand any workcover system in any state, a potential compensation claim (payout) is based on PERMANENT IMPAIRMENT. If your injury has healed, I doubt you would get anything, as workcover would have paid you for your lost time (wages when in hospital and unable to work). In VIC for example you need a whopping 30% total permanent body impairment to meet the required treshold to commence compensation payout. You would have to look in the NSW set up, but I believe regardless of the treshold you would still only be entitled to a payout if your injury is PERMANENT. You may want to get a second opinion form a non shark lawyer (free initial consultation) before making a decision though. Courts do not not look favourably on injured workers that have not tried to return to work in some capacity as the law says an injured worker has a duty to mitigate his/her own losses. So if you haven’t made an effort in seeking alternate employment, it does not look good, for they will sure argue that you can still work even with a foot injury (eg, desk work etc). Just my 2 cents worth.

  2. Worksafe wants injured workers to kill them selves just so they don’t have to pay them that’s why they drag you through hell and bully you!!!
    The system is more then broken it is in fair to real honest injured workers that can’t fight back!!!
    The Fraudulent and unethical behaviour from Worksafe is Disgusting.
    They get away with Braking the Law everyday and NO ONE DOES ANYTHING to HELP US!!!

  3. I still recommend you do not ever accept at face value whatever your WorkCover Insurer tells you about your claim. It might not be in your best interests. Always seek advice from an accredited specialist in personal injury law.

read-before-u-commentThis is a statement pointing you to our seriously injured but esteemed and honourable Social Networking Sites Warning and our comment policy. A must read in the context of a very adversarial workcover system! Remember to mention in which state you reside if you seek advice.

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