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What if a claim is rejected or notice is given that weekly payments will stop?

Once the authorised insurer/claims agent receives a workcover claim it has 28 days in which to accept or reject the claim.

If the workcover agent rejects the claim it should provide written notice of the rejection.  If it doesn’t reject the claim within the 28 days allowed, then the claim is treated as accepted.  Normally, before deciding whether to accept or reject the claim the authorised insurer or claims agent will arrange a medical examination of the worker.

What if a workcover claim is rejected or notice is given that weekly payments will stop

If a workcover claim is rejected or if a notice is received  that weekly payments will stop, and the worker wants to dispute that notice he/she must request conciliation, that is, have the matter referred to the Accident Compensation Conciliation Service (Conciliation).

If this happens the worker should contact an experienced injury lawyer who can help complete and send the necessary form(s) and if needed arrange to obtain a medical report or reports.

The aim of Conciliation is to try to resolve disputes without the need for court proceedings. All disputes must be referred to the Accident Compensation Conciliation Service as the first step before court proceedings can be taken.

In order to arrange for a disputed claim to be dealt with by the Accident Compensation Conciliation Service a Request for Conciliation form needs to be filled out and then sent to the Conciliation Service together with the notice, (if one exists) about which the worker complains.  This must be done within 60 days of receiving the notice.  It is possible to lodge a request outside that time frame, in some cases, and request an extension of time, however there is no guarantee that the extension of time will be granted by the Conciliation Service.

It is best that you seek legal advice and/or assistance!!!!

Conciliation: how it works

The Conciliation Service arranges a meeting between the worker and the WorkCover claims agent (the employer can also be present) with a view to seeing whether the dispute can be resolved.  In many cases it is helpful to obtain a medical opinion prior to the date (i.e. from your treating surgeon, GP and even a second opinion-which you are entitled to under workcover, so that you are fully ‘armed’) when the conciliation meeting is to take place regarding the worker’s condition.

If, for example, the claim for weekly payments has been rejected on the basis that the worker ’s injury has not been caused by work but rather by age degeneration it would be important to obtain a report from the worker’s treating doctor or doctors about that issue.

In the event that the treating doctor or doctors held the opinion that the worker’s condition was caused by work rather than age degeneration then that information might help persuade the WorkCover claims agent to change their decision.

A worker can be assisted and advised at the conciliation meeting.  A lawyer can only act for a worker if the WorkCover claims agent and the employer agree.  Two representation agencies, Union Assist and WorkCover Assist can help and advise workers at the conciliation level.  Their representatives assist workers at conciliation meetings. Your own union can also assist.

Union Assist can be contacted at (03) 9639 6144 and WorkCover Assist on (03) 9941 0537.

Proceedings at conciliation

The conciliation meeting

Proceedings are conducted informally. Typically the conciliator will ask the worker to explain why he or she believes they are entitled to compensation and then ask the claims agent to justify their opposition.  It is then not uncommon for the conciliator to talk to the parties separately with a view to reaching an agreement.  Often an agreement is reached.

In very limited circumstances a conciliator can order that the worker be paid the compensation he or she is seeking even if the claims agent does not agree.  However in most situations where agreement cannot be reached the conciliator either declares a genuine dispute or if the dispute is about a medical issue, refers that medical issue to a medical panel.

Note: when a matter has been settled at Conciliation, the Conciliator will issue you with a Certificate which is legally binding. Some workcover agents will ignore this binding certificate and when confronted may tell you lies such as that “they were not aware of it or that they had misplaced the certificate etc etc.”If (and when) this happens (that is – when the workcover agent ignores the ACCS ruling) you must immediately contact (per telephone) the conciliator who dealt with your matter (his/her details will be on your certificate, incl. a reference number) who will (or should) rectify the matter. You should also put a formal complaint in with WorkSafe.

And after that hold tight because in all likelihood a few months down the track,the whole procedure will start all over again as workcover will continue their uttermost best to deny you what you are legally entitled to. So IMEs will start again, followed by threats, followed by ceasing of decreasing a ‘benefit’,…, and so the vicious circle goes on and on and on…

If you don’t have legal representation, the workcover agents are known to piss you around even more, because they know they can get away with virtually anything!

Medical panel

If a conciliation officer refers a medical question to a medical panel, the medical panel is required to provide an answer to the medical question within 60 days. The medical panel usually consists of 2 or 3 doctors selected from a register of medical practitioners.

The decision of the medical panel is binding (although recently the High Court has debated this).  For example, if the conciliation officer asked the medical panel to decide how a worker’s injury had been caused, eg. whether a back injury was the result of work or age, then the medical panel’s decision determines the issue.  Other than in exceptional circumstances, there is no appeal from a medical panel decision to a court.

The procedure the medical panel normally adopts is to arrange for an examination of the worker.  The panel typically question and examine the worker on the one occasion.  They then give written answers to the questions they have been asked and also an opinion setting out the reasons why they have answered the questions in the way they have.  Both the answers to the questions and the written opinion are available to the worker concerned and his or her representatives.

A worker, employer and the WorkCover claims agents have the right to submit documents to the medical panel which they regard as being relevant and the documents which are submitted by the claims agents and the employer should be available to the worker so that he or she can point out any inaccuracies or mistakes in the documents, either before the panel meeting or when in front of the panel.

Court proceedings

If the conciliation service cannot resolve the dispute between the parties by discussion and the matter has not been referred to a medical panel to make a decision, then a worker is entitled to take his or her matter to court.  Most court proceedings are taken in the Magistrates Court.  Some cases are taken to the County Court. Even if court proceedings have been commenced, either party has the right to have a medical question referred to a medical panel.

If a court refers a dispute to a medical panel then the findings of the medical panel are binding. That means that even if the Magistrate or Judge hearing the case were to disagree with the medical panel, the Magistrate or Judge would have to make a decision consistent with the medical panel findings. If the dispute has been taken to court and not referred to a medical panel, it is then decided by a Magistrate or Judge.  Each party calls its witnesses including doctors and the Magistrate or Judge makes a decision about the dispute.

Are you entitled to Superannuanuation whilst receiving WorkCover payments?

Superannuation contributions – Do you have an entitlement whilst receiving workcover payments?

The law governing workcover claims was again amended in 2010 to give injured workers an entitlement to Superannuation contributions, whilst they are receiving weekly payments.

If you have sustained a workplace injury on or after 5 April 2010 and:

  • You have received 52 weeks of weekly payments;
  • Your weekly payments are continuing;
  • You have not reached the age of 65; and
  • Your employer has not paid contributions on your behalf

You will be eligible to receive Superannuation contributions paid into your nominated Superannuation Fund.

It is the responsibility of the workcover insurer handling your claim to notify you of your eligibility for Superannuation contribution payments.

If you are eligible, you must nominate a Superannuation Fund.

The contributions will be paid at the guarantee rate (currently 9%) of your weekly payments amount.

 

Unfortunately for those injured before the 5th of April 2010, no superannuation contributions will be made… which makes me wonder what’s going to happen to me when I reach 65?

Sometimes it’s worth waiting or delaying serious injury

Waiting for Serious injury

For some injured workers, it is not immediately obvious whether they suffer from a serious injury. Often an injury will be troublesome and cause some ongoing pain and restrictions, but it is uncertain whether it will meet the strict legal test of “serious injury”. As an injured worker only gets to apply for a serious injury once it is important that the claim is not made prematurely.

In a recent case , a young workcover victim, in his late 30’s, who had been under a solicitor’s care for many years, had initially injured his back at work lifting a heavy device in 2001. He had a short time off work and then despite some ongoing pain in his back, returned to normal duties. He continued on like this for many years. At times he would have flare ups of back pain that kept him out of work for a few weeks a time, but mostly he was able to manage things. However by 2010, his condition had deteriorated so badly that he required surgery to be performed to his back. He has, however, since been able to return to work and therefore his claim would be for pain and suffering only (and not for economic loss).

Whilst the injured person was initially very keen to settle the claim and get compensation, his lawyers advised him to wait because- from their experience- they feared that he may still deteriorate.  Sadly for him that is what happened. But by having held off his claim, it meant that when he eventually did proceed with it, he was able to get proper compensation for all of his pain and suffering, including the need for surgery.

In my own case, although I have been whingeing about not being able to get through the Medical Panel’s impairment assessment for 3 years in a row because the injury was deemed “unstable”, looking back I am so glad I did not pass, as my injury has since then deteriorated so much that I now already have received close to 30% from the workcover insurance (my first NOA -Notice of Assessment was 19%!!!) alone – just add to that a fair assessment and I will be well over 30% and entitled to pursue a common law damages claim!

Lesson: If you are able to manage financially, that is: survive on your weekly payments; or if your are still working part time (or full time) and your injury involves particularly a back injury, spine, neck or a severe orthopedic injury (i.e.hip, shoulder), chances are that you WILL get worse (think arthritis, think failing of previous surgery, think additional wear and tear, overuse of weakened limb/area) then PLEASE hang on and DON’T RUSH to settle your claim (as in permanent impairment assessment and lumpsum)! You ONLY GET ONE (1) GO AT IT!!!!

Just imagine the following: you injured your shoulder at work, didn’t seem too serious initially. You had routine surgery. Recovered. Went back to work. A few months later you noticed that your shoulder was getting unstable again…You did not think much of it (hey, you had surgery a few months ago)and just carried on working. Had your impairment assessment, got 12 % total body impairment and what something like $25,000. That’s it. Paid off some debt, your lawyer and had a well deserved holiday. Then the problems started – your shoulder really started to hurt. Went back to the doc , had more scans and now they tell you you they did not pick up that you had an additional injury to the shoulder (let’s say a backwards dislocation and torn labrum). You need more surgery. After the surgery you bloody well get an infection in the shoulder, need wash outs and debridements and all surgical repairs fall apart…You’re off work for months, then for a year, then two years. The shoulder is reconstructed but it fails. Now you need a shoulder replacement (prosthesis) and have been told that you will never work again. Well, my friend, you are truly stuffed. You had accepted the permanent impairment some years ago and received your pathetic lumpsum (now long gone). You are NOT entitled to a common law damages claim for pain and suffering or economic loss because you accepted a 12% total body impairment, and you need 30% (which you would easily get now). See what I am saying?

Be very very careful and make very sure (as sure as you possibly can) that your injury will not deteriorate.

 

This has happened to quite a few injured people and it is extremely devastating for them, and in a way unjust for there should be a way in our laws that allows for “unforeseeable deterioration” too.

Time frames to lodge a serious injury claim

An injured worker has 6 years (from the date of the injury) to lodge a serious injury claim in Victoria.  As long as the worker’s limitations period is protected, there should be no rush to lodge a serious injury claim – unless of course the injured worker wants to.

Sadly for most workers, injuries frequently get worse over time and for the serious injury consequences to be fully apparent, it is often better not to rush these cases. This above story and my story is reminder of that.

Obtaining household help and assistive appliances under workcover

A few weeks ago I posted a story about how to obtain home help under workcover. Here is the follow-up story of that mind numbing process…

The process of requesting home or household help under workcover recap

“WorkCover can pay for the reasonable costs of household help services to assist in the rehabilitation from your work-related injury or illness, in accordance with section 99 of the Accident Compensation Act 1985 (the Act)”.

1. Your treating GP writes a letter to your (very dumb) case manager, requesting you be provided with home help. Your GP needs to detail the reasons why the home help is necessary, even if you have a massive file and plenty of supportive evidence on file with your workcover insurance, because – remember- your case manager is a donkey and does not understand how an injured person would possibly need help with managing the household

2. Your case manager may use delay tactics and write back to you that the letter from your GP does not provide “clinical justification” for the need for home help. In my case my GP wrote that I had  a SEVERELY painful and GROSSLY unstable [limb] and that was not a good enough reason – yeah right… Don’t give up! Go back to your GP at the cost of your workcover insurance and have him/her write a new letter using baby language such as “has an extremely painful and grossly unstable [limb] because of the work injury and therefore has only partial use on 1 [limb] making washing dishes impossible, making ironing impossible, mopping a floor is not possible, the vacuum cleaner is too heavy to drag around with 1 arm, cleaning the bath is impossible, making a bed and changing linen cannot be done using 1 hand, she/he is unable to prepare food and cook using 1 hand, ha/she can not eat alone without assistance (i.e. husband needs to cut meat etc) etc etc. I kid you not!

3. Your case manager now accepts the referral for a home help assessment. She/he will send an Occupational Therapist of his/her own choice (you have NO say in who will be sitting with you in your own house for hours) to undertake an “interview” and then, if necessary, to conduct a functional assessment and, possibly an education session.

4. The Occupational Therapist prepares a huge report which is sent to the case manager for review/consideration and/or approval

5. Your case manager sends you a letter with the outcome (decision)of the request for home help. If you are not happy with the decision you can of course appeal it at the ACCS.

 

My request for household help services under workcover

To begin with and most interestingly, when I received (under the FoI Act) a copy of the home help assessment I noticed that the workcover insurance had only given to the Occupational Therapist one (1) old report from my treating surgeon dated 2010 (since then I have had further tests showing catastrophic deterioration etc etc and now also have a bone infection), and – very interestingly- several reports from IME psychiatrists – what the f**k for???? We’re talking about the physical ability to perform household tasks here, right. So, here they start again covering up the extent of your injuries so that they can manipulate the Occupational Therapist and thus deny you household/home help.

According to the letter from the workcover insurance, the home help assessment (by the Occupational Therapist of their choice) was done “to identify the household tasks that you are able to complete independently, and the assistance you may require to achieve independence with household tasks“… READ this carefully… Note the repeated words “independent“.

The letter further states (2nd paragraph) that “[the workcover insurance company] is committed to assisting you to maximise your independence with household tasks“.

Do we need to read the letter further? What do you think the answer will be to my/our request for the much needed home help?

You are right! The answer is NO.

The letter states (paragraph 3) that “…we have THOROUGHLY reviewed all the information provided by yourself, your treating GP and the Occupational Therapist. We have also very CAREFULLY considered your individual circumstances, the Act and relevant WorkSafe policy and Guidelines..”

(Paragraph 4). “Based on this [the workcover insurance] are UNABLE TO APPROVE the reasonable cost of home help services“.

Now consider this:

But I am NOT entitled to household help. Who gives a shit that I can’t wash my hair, get dressed alone, go shopping, prepare a meal, who gives a shit that I can’t wash the dishes, mop the floor, hoover, make a bed, iron my clothes, wash my clothes, hang my clothes on a washing line, who gives a shit that I can’t open a bottle of coke, put butter on a slice of toast, brush my teeth, and let’s not even mention bigger things like mowing the lawn, getting rid of cob webs, cleaning windows. Who cares, for I just happened to loose my fu****g life because I happened to be assaulted by a patient at work! I had been working for 20 years, saving lives and helping other people, and with a smile… but now that I need a little bit of help, I just am not entitled to it, or so says the workcover insurance.

What does it take to be entitled to home help?

I am horrified and deeply deeply hurt.

However, in paragraph 5, the workcover insurance is feeling very generous, because they write that: “…we will pay for the reasonable cost of the following assistive equipment as detailed below and attached with this notice…”. Oh my, thank you, I am in awe!

“The following occupational therapy services are approved to HELP YOU MAXIMISE YOUR INDEPENDENCE but ONLY once we RECEIVE A REFERRAL FROM YOUR TREATING DOCTOR APPROVING THE PURCHASE OF THIS EQUIPMENT”:

  • long handled toilet brush to clean the toilet – oh thank you so so much
  • long handled tile and bathroom SCRUBBER – oh dear I don’t know what I’d do without it
  • mr peggs handy washing line – oh, too generous really – still doesn’t solve my problem not being able to use both hands though
  • knife and fork in one: oh god, at least something useful
  • plate guard: jeezus, this may just help me spilling my food off my plate when I eat and make the place a little less dirty
  • steam floor mop: oh my… and how am I going to use a steam mop?

So, now my GP needs to fu**ing approve these items – Oh my, it’s obviously a tricky medical question, isn’t it? I mean surely you need a panel of doctors to approve a knife/fork in one and a plate guard for a person with 1 arm. Jeezus.

And… who’s gonna wash the dishes?

Another dirty trick to keep in mind when you get your home help assessment done

There is a specific question asked by the workcover insurance company to the Occupational Therapist who does the assessment and that questions is:

OBSERVATIONAL AND CORRELATION BETWEEN OBSERVED AND REPORTED DATA

The Occupational therapist (of THEIR choice remember) will watch your every move and write it ALL down. For example any movement you make, how many minutes you stand, sit, how you drank your cuppa, EVERYTHING. WATCH OUT!!!!

To finish this post, I can’t help but laugh or cry when I read that the Occupational Therapist (of THEIR choice) wrote that with the above appliances/assistive aids I should be able to “clean the house over a period of 21 days” (at 3 minute intervals!). For God’s sake.

Also the Occupational Therapist made a note under the report’s “General Presentation” heading: it states that ” the floors are very dirty and untidy and in urgent need to cleaning, the dirty dishes are piled up and need urgent cleaning”.

More info about home and household help can be found in the online claims manual (Vic) under “entitlements/Medical and like services”

All I can say is that the workcover system is corrupt, unfair and fully sick. Consider that many of us, seriously injured ‘workers’ have, understandably, developed a secondary depression because of our injuries, disabilities and the impact it has on our daily lives… now add the way we are being treated by workcover insurances and denied over and over again what we are legally entitled to…no wonder we become severely depressed and just don’t see light at the end of the tunnel any more. At least I don’t.

 

WorkCover: Survival guide for injured workers

Here is what I call my “Survival Guide” to workcover because injured workers who are placed on workers’ compensation without the benefit of experienced lawyers on their side are left to rely upon human resource managers, workers’ compensation insurance case managers and claims adjusters for advice and information regarding their workers’ compensation rights.

All too often, injured workers mistakenly believe that workers’ compensation insurance is their insurance.  Nothing could be further from the truth! Rather, workers’ compensation insurance is insurance for the employer, and an injured worker is considered a “claimant.” In fact, Australian laws are written in such a way that the workers’ compensation system has become a system of the injured worker versus the insurance company (and the employer)!

The average injured worker placed on workers’ compensation has no understanding of the system and is left to trust the workers’ compensation insurance company (and their employer) to protect his/her rights.  A workcovervictimsdiary believe that such trust is misplaced.

The Survival Guide to WorkCover has been prepared with the hope that it would help injured workers identify the red flags!

Survival Guide to workcover

1. Be sure your injury description is correct

When a worker is injured on the job, the law requires the workers’ compensation insurance companies to issue a  Notice of Compensation Payable/ notice of injury/accepted liability, if liability is accepted for the injury,which represents the employer’s and insurer’s legal recognition of a work injury. It contains a description of the injury and sets forth the employee’s average weekly wage. The Notice of Compensation  is prepared by the workers’ compensation insurance company, and often the description of the employee’s injury is not accurate. It is very common for the insurance company to describe the injury as less severe than it really is.  For example, an employee might injure his/her wrist on the job and go to the hospital’s emergency room for treatment.  X-rays reveal that the wrist is fractured, but when the injured worker receives the Notice, the injury is described as a wrist sprain.  Many employees do not even look at the injury description when they receive the document. However, an inaccurate injury description almost always favours the insurance company and hurts the injured worker. The Notice  should have an accurate injury description.  If the nature of the injury has changed, for instance,  if a low back sprain is later determined to be a herniated lumbar disc after an MRI, the Notice  should be changed to reflect the diagnosis of the more serious condition.

In my case, 7 years after the incident and 7 major surgeries later, the Insurance Company I deal with still writes “bruised [limb]! That the [limb] is fractured and broken beyond repair, qualifies as a ‘serious injury’, and even whilst the insurance company issued me (later) with a notice of assessment (for impairment) of 26%, they continue to just write that I have a “bruised [limb]. Even when they send me to an IME or a Medical Panel, their diagnosis of just a “bruised [limb]” remains unchanged…. yeah, right…

If you receive a Notice of injury and the diagnosis of your injury is not correct, you should contact your lawyer

2. Be sure your wage rate is accurate

The Notice of Compensation Payable referred to in Survival Tip #1 also includes the injured worker’s pre-injury average weekly earnings (PIAWE). The workers’ compensation insurance company calculates the average weekly wage by using one of several possible formulas, which are selected depending on the injured worker’s individual circumstances. The average weekly wage should include salary and/or hourly wages, overtime, and bonuses. It may be adjusted for seasonal employment and  should include income from other employment.

Mistakes in calculating the average weekly wage are often made.

Failure to review the calculations may result in an underpayment to an injured worker that goes undiscovered.

Always ask to see how the workcover insurance company calculated your PIAWE and double check it to make sure it is correct.

3. Always document receipt of late payments (whether in your bank account or via cheque)

Late payments are a common complaint of workers receiving workers’ compensation benefits.

The law requires workers’ compensation insurance companies issue wage loss benefit cheques/payments in the same pay period that the injured worker would have received his/her regular pay. For example, if you were paid weekly before the injury, you should receive your workers’ compensation payment weekly.

Always

  • Make a  copy of the cheque/payment when it is received.
  • If you receive cheques, attach the copy of the cheque and any cheque stub that accompanied the cheque to the  envelope in which the check came.
  • Write the date that you received the cheque on the envelope or copy your bank statement(s)

Your lawyer can then use this documentary evidence to prove that the workers’ compensation insurance company is not sending the cheques/payments in a timely or consistent manner.

After all the years that I have been receiving workcover payments (initially on and off  as I was still working in between surgeries until about 2 years ago,when I had to stop working), it still surprises me how often my employer/workcover “forgets” to pay me, and what amazes me most is that payment amounts will occasionally vary!!!!

Regardless of whether your cheques/payments are late, we recommend that all injured workers keep a log of when they receive the cheque/payment and what period they covered.

4.Know the significance of an independent medical examination (IME)

An Independent Medical Examination (IME) is a tool used by the workers’ compensation insurance company to have its own “so called independent doctor” of choice review the physical condition of an injured worker. The Independent Medical Examiner,  a doctor chosen and paid by the workers’ compensation insurance company, will review an injured worker’s medical records and examine the injured worker. The IME doctor will then issue a written report to the workers’ compensation insurance company. A copy of that written report is usually not provided to the injured worker, but you are entitled to a copy under the ACA or the Freedom of Information Act (make sure you obtain a copy).

An IME costs the workers’ compensation insurance company money.  Therefore, it is usually only requested when the insurance company feels it may disagree with the injured worker’s treating doctor, and wants to interfere with that treatment or refuse to pay for it. The other reason that an insurance company will request an IME is that it disagrees with the treating doctor’s restrictions on the injured worker. In those instances, the workcover insurance company requests an IME to force an injured worker to do more work than is recommended by his/her treating physician. In either event, AN IME ALWAYS SPELLS TROUBLE!

5. Know who’s side workcover, including your case manager is on

Injured workers have the right to choose their own doctors and specialists.

Workers’ compensation law provides the injured worker with the right to control his or her own medical treatment.

Workcover insurance companies must also provide you with a list of at least three (3) Occupational Rehabilitation Service providers. Don’t just accept who they are sending you to!

The case manager will report to the insurance company on the treating doctor’s recommendations and even on your own “feedback” and will often guide an injured worker to other doctors or specialists.  The injured worker should be aware of the fact that while everyone, including the workcover insurance company, has an interest in seeing that the injured worker gets better (i.e. returns to work), there is a great advantage to the workers’ compensation insurance company if it is able to control medical treatment. You do not have to talk to the case manager. Don’t provide any “feedback” on treatment plans from your doctor etc.

6. The workers’ compensation insurance company is required to reimburse the injured worker for travel expenses.

This includes:

  • Kilometers (petrol) if you use your own car
  • Parking fees (keep receipts or take a picture of the digital parking meter if no receipts are given)
  • Travel costs to any treatment/appointment needed for your injury: this can be physio, psychology, GP, specialist, massage etc
  • Medical Panel
  • Accident Compensation Conciliation Service (ACCS) travel cost must also be paid

7. Be careful of Vocational Assessment and the identification of “suitable” jobs

A vocational expert hired by the insurance company compiles a Labour Market Report with “identified suitable jobs”, and the insurance company’s lawyers may introduce that report at a hearing before a workers’ compensation judge and request that an injured worker’s weekly wage loss benefits be reduced or stopped altogether.

They will go out of their way to find you the most outrageous ‘suitable’ or ‘light duties’, often without consulting you or taking your restrictions into account.

True story:

I had been employed for almost 10 years with the same employer where I sustained my severe injury. My original employment was terminated within weeks of my injury as medical reports proved that I would never be able to work in that “field” again. Suitable duties were allocated – hey your employer has a duty to care for you for 52 weeks (1 year) and cannot sack you during that period. The so called suitable duties were physically worse/harder than my original job! So I looked for another job within the organisation by myself, which was more sedentary and desk-based.(BTW I retrained as well via internal courses and 1 TAFE course). I obtained in total 3 independent contracts (jobs) during a period of 5 years AFTER the accident and AFTER my original employment had been terminated. I was working as a X Manager in my last full-time job and had independently obtained this position by legal means (interview, selection process etc). I had made it very clear at the time of my interview that I was ‘disabled’ and that I required reasonable  ergonomic tools in the workplace as well as some flexibility (good days/very bad days). All was accepted and I was still deemed the best candidate for the job. About 6 months down the track it became unfortunately clear that I would require further major surgery. The injury had again deteriorated, again because my employer had still not put in place the medically requested, reasonable ergonomic tools to assist me (we’re talking about simple things such as chair with support, docking station for the laptop, alternative mouse, under-desk keyboard drawer etc). My employer was well aware of the type of surgery I was to undergo and knew that I would most likely lose more function (in my limb) in exchange for pain control. It was a salvage operation. They also knew that the ergonomic tools would still be necessary, even more so. Guess what, after the last surgery, and whilst I obtained a legal certificate of capacity from my surgeon allowing me to undertake the same duties as before the surgery 6 weeks after the surgery, my employer sacked me – just like that. It was obviously fine for me to work full time up to the day before the last surgery in a very bad physical state and with no ergonomic support, but after the surgery I was ‘not good enough’ anymore I suppose.

Within DAYS of my sacking, my case manager started calling me (up to 10 times a day) stating that I could and would work and that she would send me to a vocational. Needless to say that I questioned the need for a Vocational assessment, given that I had been working as very successful X manager for several years. So why the need to find a new vocation?

Anyway, it turns out that, setting aside their desperation to get me a job (of which by the way several positions were open in the same field), they were looking at making me work in “identified labour market jobs”. I will spare you the details but whilst I have been working my whole life in health care, they felt that I could work as a “ministerial assistant” and – take a deep breath- that “I had experience in that area: as in preparing briefing documents for a minister” – yeah, right… Another job that I was deemed capable of was to work as a X clerk! I mean I get sacked from an executive management position in the health care system (for which I am well qualified), and which involved desk work (report writing, analysis, coaching and training, project work etc), but now I need to work  as a X clerk,which involves running around all day, photocopying documents, filling water jugs, making coffee, answering calls… yeah right… Not only is this clerk job so insulting, but – the important part- the job is hands-on and here I am sacked by my own employer because “I am disabled” and “can’t do a desk job”. Please explain!!!!

If you have been injured at work and it appears that you may be unable to return to your pre-injury job, you should contact your lawyer immediately.

8. Make sure your medical (and related) bills are paid and on time

If you are already receiving workers’ compensation benefits, you should be aware of the fact that your medical treatment can be subject to  an ‘Victoria/whatever state WorkCover Autority Clinical panel review’. This is a process in which the insurance company challenges whether your medical treatment is reasonable and necessary, not whether the treatment is related to the injury.  Once the workcover insurance company receives the medical provider’s bills/accounts and notes, it can file for this Clinical Panel review, which allows the insurance company to avoid paying for the treatment. When the insurance company does this, supposedly, a medical provider with the same specialty as your medical provider reviews the treatment.

You should know that you cannot be held responsible for paying the medical bill and you can take an appeal of that panel review’s decision. In fact, this clinical panel review is not only available to the insurance company—you, too, can file for a review if necessary.  If you receive a  Clinical Panel Review Determination or think the insurance company is refusing to pay for treatment recommended by your doctor, call your lawyer or the ACCS to find out your rights.

Usually you can appeal the decision at the ACCS, and just provide your own “evidence” from your supporting treaters that you do need the treatment.

In my case workcover has attempted to cease my psychology treatments several times and recently also decided that I did not need physiotherapy. Between brackets I am to undergo an 8th major operation to a joint (limb), but hey I don’t need physiotherapy for that, do I? Get a grip!

Often a WorkCover insurance company will not pay for a medical bill because it believes the treatment is not related to the work injury. You should not let these bills sit around even though you know they are related to the work injury.  By not dealing with the issue, the bill could be reported to a collection agency and the doctor could even refuse to treat you.

For example: I was recently told by a fellow workcover victim that workcover refuses to pay for Eye drops and Eye ointment. These eye treatments were prescribed by the injured person’s specialist to alleviate eye issues (dry eyes etc) that came about as a known side effect from an anti-depressant the person needs to take.

In another case, workcover refused to pay for an ultrasound of an injured person’s leg stating that “the leg injury had nothing to do with the original shoulder injury”. Well, that person had undergone massive surgery whereby the hamstrings of the injured person’s leg were harvested and transplanted into the person’s shoulder for reconstruction. jeezus, aleluja….

9. Prepare for your Impairment Rating Assessment

Impairment Rating Assessments are a tool used by the workers’ compensation insurance company to assess your total body impairment and subsequent lump sum payout. So it is about how much the workers’ compensation insurance company will have to pay to the injured worker. The workers’ compensation insurance company gets to start the Impairment Rating process and controls the records which are reviewed by their chosen physician.

Needless to say that the “independent impairment assessors/doctors” are not only chosen by workcover, but they also happen to be paid for by workcover. Workcover insurance companies will go at great length to have your impairment assessed by the most dishonest, incompetent “assessor(s)” – remember its about MONEY.

In my case workcover sent me to an “occupational physician” to assess a highly complex orthopedic injury. Not only was he rude, but he was very good a covering up certain injuries or the severity of injuries. What does an occupational physician know about RSD or CRPS for example, what does he know about an 7 times operated upon joint?

The law also provides a way to challenge an Impairment Rating Assessment. Usually the way to appeal an impairment assessment is via the Medical Panel. You should contact your lawyer.

Never ever sign a Notice of Assessment without seeking legal advice!

10. Offers of settlement for a lumpsum

Needless to say, there is typically a very large difference of opinion as to what a workers’ compensation insurance company wants to pay and what an injured worker should accept. The amount offered relates to the total body impairment as assessed by their doctor of choice. It is important to remember that the workers’ compensation insurance company cannot make an injured worker accept a settlement. (see above) Many times, a settlement, even when it provides for a large payment, is not in the injured worker’s favour. Don’t get fooled by the little bold clause stating “that if you accept the offer the money will be in your account within 14 days”, no matter how poor you are.

How to fill in your work injury claim form

If you have had an accident at work then you should make sure you follow some simple steps which will help make your personal injury claim a lot easier.

To begin with you should make sure you have reported your accident to someone within the company and then should have noted it down within the company’s book.

Although some people think it isn’t always important to note an accident at work it is no matter how small the injury should always be noted down and you should always alert the health and safety officer on site who will make a note.

Accessing and completing the claim form

A worker can access a Worker’s Injury Claim Form (Claim Form) from the following places:

·         their employer

·         the agent

·         an Australian post office or outlet

·         WorkSafe Advisory Service

·         a writeable PDF version of the Claim Form available on the WorkSafe website.

Where the worker chooses to access the writeable PDF version of the Claim Form they will have the choice to:

·         print the form off and complete it by hand by writing clearly with a pen

or

·         complete the form online before printing it off to sign the declaration.

The worker must sign the Authority to Release Medical Information and Declaration in the Claim Form for it to be considered valid.

What fields need particular attention

It is extremely important that you give as much information possible about the “injury/condition” you sustained.

For example: just writing “hurt my shoulder” whilst lifting a heavy box is not really sufficient, because later on, workcover may argue that any “additional/other injuries” you sustained (became aware of later) were not reported on the claim form and therefore they won’t accept liability. This becomes extremely important later on when you will claim impairment benefits under section 98C of the Act.

So it is best that you write as much information as possible about the ‘injury’; for example: “hurt my Right (or Left) shoulder and arm whilst lifting” – then add what exactly you felt, for example ” I felt a clunk in my right shoulder; I had pins and needles along the entire arm; my neck also hurts as well as the right side of my back…”. Here you have covered yourself for a potential injury to your shoulder,your arm, your neck, your back, a nerve.

Example of a “good injury claim form”

A fellow worker fell from a ladder at work and hurt his right shoulder. He wrote on the claim form that he had fallen off a ladder and landed on his right shoulder/right arm and felt pain in the right shoulder/right arm/right side of neck and right side of body. He not only had a fractured shoulder, but later on it was discovered that he also had a neck injury for which he had to have surgery. Whilst he only had a little bit of tenderness in the neck at the time of the incident (and nearly did not bother writing this on the claim form) he ended up with major surgery to the neck. Had he not mentioned the neck pain (however slight) workcover may have not admitted liability for his neck injury!

 

 

Medical and Like Services: Know your entitlements

Did you know that you are entitled to heaps of Medical and Like services under the workcover Act?

  • Acupuncture:

WorkSafe can pay the reasonable cost of acupuncture services at the request of a medical practitioner if those services are required as a result of a work-related injury or illness.

  • Aids and appliances

Workers are entitled to be compensated for the reasonable costs of personal and household services incurred because of the work place injury.

The definition of a personal or household service includes aids, appliances and apparatus.

To be eligible for reimbursement, these services are to be requested by a registered medical practitioner.

  • Attendant Care

The accident compensation legislation states that workers are eligible for reimbursement for ‘personal and household services’ and the definition of a personal or household service includes attendant care. The legislation also specifies that these services are required to be provided by a person who is approved by WorkSafe.

Attendant care is most often required:

to assist a severely injured worker who is dependent on assistance for aspects of movement, self-care, toileting and activity; to facilitate community access, assistance in social activities and vocational return to work; as part of a hospital discharge plan, which forms the basis of a structured holistic program.

Attendant care is provided to workers to assist with activities of daily living, including: personal care – showering, bathing, dressing, toileting, grooming, eating, drinking, preparation of specially prescribed foods, monitoring of medication, assistance with use of specialised equipment; program implementation – implementation of goal oriented programs, conduct of physical exercise, programs designed to increase skills of daily living; community access and recreation – providing 1:1 support for the attendance at and participation in events and activities;  respite – providing care for a worker to allow the family respite.

You can also request for friends or family members being paid to provide attendant care!!!

Will require medical evidence and support from the treating medical practitioner.

  • Burial/Cremation

WorkSafe can pay the reasonable costs for a burial or cremation incurred within Australia when a worker dies as a result of a work-related injury and there is an accepted WorkSafe claim for the death of the worker.

  • Car modification

WorkSafe can pay the reasonable costs of modifications to a car that are reasonably required as a result of a worker’s injury or illness to enable the worker to drive or to be transported safely (examples:non-functional arm: include a  spinner knob, t indicator extension, modified accessory controls; adjusted mirrors, seat belts, harnesses etc)

Where a worker’s car cannot be modified or the worker does not have access to a car, WorkSafe may contribute a reasonable amount to the purchase cost of a suitable car selected by WorkSafe.

  • Childcare services

WorkSafe can pay the reasonable cost of childcare services at the request of a medical practitioner if those services are required as a direct result of a work-related injury or illness and supported by an independent OT assessment as being necessary and appropriate.

For example, if  you are unable to provide childcare as a result of your injury or illness you can get child care services!

  • Chiropractic

WorkSafe considers chiropractic to be a primary contact service. A referral from a medical practitioner is therefore not required.

  • Community access

WorkSafe recognises that some eligible workers may acquire multiple physical, sensory and cognitive disabilities, which may impact on their ability to access and participate in their social and recreational activities.

Community access services are designed to assist eligible workers to increase their participation in the community by identifying and responding to their individual needs through Community Access Planning and Community Group Programs. These services may be provided to an eligible worker separately or in combination depending on the needs of the worker.

Community access planning is the services provided by a community access planner to an eligible injured worker which aims to: maintain and enhance peer support networks, and facilitate sharing of authorised support services; assess and review the support needed to enable a worker to participate in community bases social or recreational activities; link workers into community bases social or recreational activities; monitor a workers participation in community activities to ensure programs continue to appropriately address the workers needs.

Community group program is an individually tailored program of supported group activities which: is provided within community based facilities; is specifically designed for eligible workers who require support; to engage in social or recreational activities outside the home; supports the development of peer support networks, community living and social skills.

A referral is required from a medical practitioner for the provision of any approved health service with the exception of medical, physiotherapy, osteopathic, chiropractic, optometry, dental and podiatry services.

  • Dental services

WorkSafe can pay the reasonable costs of dental services (including oral and maxillofacial surgery) as a result of a work related injury or illness.

Note: Prior approval is not required for emergency dental treatment requests relating to a work-related injury or illness.

  • Dietetic services

WorkSafe can pay the reasonable cost of dietetic services at the request of a medical practitioner if those services are required as a direct result of a work-related injury or illness.

Note: WorkSafe will not pay for weight loss programs or food/meal replacement services, for example home delivered meal services such as Lite n’ easy or weight loss programs such as Weight Watchers or Jenny Craig.

  • Elective surgery

Elective surgery is clinically necessary, non-emergency surgical treatment (including surgical procedures) performed by a suitably qualified medical practitioner.

Prior written approval from the agent is required for elective surgery. You can have your surgery in a private hospital.

Note: Worksafe will not pay for services provided outside of Australia without prior approval from the agent

  • Equipment and related services

WorkSafe can pay the reasonable costs of equipment and related services to assist a worker in the rehabilitation of a work-related injury or illness, or whose work-related injury or illness has caused impaired function in any of the worker’s activities of daily living.

To consider paying for aids and appliances, WorkSafe requires the following information:

·         A current referral from a medical practitioner for any equipment and related services.  To assess a worker’s eligibility for equipment, WorkSafe also requires a written recommendation from the worker’s treating therapist or relevant healthcare provider

·         For wheelchairs, pressure cushions, beds, mattresses, powered conversion kits, scooters, standing frames, lounge chairs, customised toilet/commode/shower chairs or hoists, an Equipment Prescription Form must be completed by the prescribing therapist and submitted to the Agent.

WorkSafe can pay the reasonable costs of equipment and related services that are reasonable and/or necessary for the worker’s work-related injury or illness.

WorkSafe will take into account whether the equipment and related services will:

·         increase independence

·         facilitate a return to vocational, educational or leisure activities

·         improve mobility

·         relieve pain/discomfort

·         ensure a safe environment

·         aid communication/swallowing management.

Examples: taping – zinc oxide, fixomull, strapping, etc; bandages – compression, tubigrip, thera-band, gauze products; oedema control and dressing bandage;  thermal supports, pressure garments and gloves; soft collars; hand putty/thera-putty digiflex, exercise foam; walking sticks, triangular slings; plaster, ice packs, heat packs; hibitane, iso-wipes, skin-prep, applicators; adaptive cutlery; dressings aids (example, long handled sponge/shoe horn, toe wiper, sock aids, button hooks, elastic shoe laces); pick up sticks.

  • Exercise physiology

In order for WorkSafe to consider payment of the reasonable costs of exercise physiology the medical practitioner referral must be provided to the agent by the worker or healthcare provider.

  • External case management

External case management is a collaborative process with may include an assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and the utilisation of available resources to promote quality cost effective outcomes.

WorkSafe recognises that some eligible workers at certain times require assistance beyond the case management role of an agent or the role of treating health care providers. Case management services are a time-limited service that complements the agent’s role.

A referral is required from a medical practitioner for the provision of any approved health service with the exception of medical, physiotherapy, osteopathic, chiropractic, optometry, dental and podiatry services.

  • Gym and swimming programs

WorkSafe can pay the reasonable costs of a gym and/or swimming program at the request of a medical practitioner if those services are required as a result of a work-related injury or illness and to transition to a self-managed exercise program.

Written approval from the agent is required for a gym or swim program.

Example: You have injured your knee – you are allowed to attend gym to strengthen your upper body (arms etc)!!!

  • Hearing services and devices

WorkSafe can pay the reasonable costs of approved hearing services and devices provided by WorkSafe approved hearing service providers to assist workers in the rehabilitation of work-related injuries or illness under s99 of the Accident Compensation Act 1985.

  • Home modification

WorkSafe can pay the reasonable costs of modifications to a home in which a worker resides in Australia, where the modifications are reasonably required as a result of a work-related injury or illness and will impact on a worker’s access to and function within the home.

If a worker’s home cannot be reasonably modified for any reason, WorkSafe may contribute a reasonable amount to the purchase cost of a semi-detached portable unit or to the costs of relocating the worker to another home that is suitable for the worker or is capable of being reasonably modified.

Major Home modifications include: Any modification/contribution made by the agent for an amount greater than $10,000 where structural changes are necessary (eg moving internal walls or enlarging existing rooms) and/or extensive modifications in and around the house eg ramps, carports, bathroom and/or bedroom.

Minor Home modifications cost less than $10000 and include things like holding bars for the bath, different locks on doors; holding bar for toilet; rails etc.

Requests for home modifications can be initiated by any party, worker, family, medical and health practitioners, hospital but the actual home modification recommendations must be submitted by an Occupational Therapist (OT).

  • Household help

Household help refers to the provision of services for basic and routine common housework and gardening tasks that the worker performed pre-injury and are essential for maintaining the worker in the home.This also applies to injured workers who are living with a partner/spouse.

A referral is required from the worker’s treating medical practitioner. The treating medical practitioner must provide supporting evidence.

Note: WorkSafe will not pay for: the cost of cleaning materials;  food items; standard housework or household appliances; self care tasks including bathing, dressing or personal grooming; pet care; support of hobbies or personal lifestyle interests. For example: hobby farm, animal breeding or showing;  car care; home or furniture maintenance including window washing, cleaning or drapes blinds or carpets; home modifications including painting, renovation or modification; property maintenance or repair including painting, watering gardens, gutter cleaning or maintaining paving;  the cost of garden implements unless recommended by an OT as modification or assistive equipment for the  worker;  raw materials. For example: plants or mulch; fees for rubbish or grass removal.

  • Implantable pain therapy

Implantable Pain Therapy (IPT) is a procedure involving the use of an implantable device to address persistent pain and may be considered when a range of alternatives for managing persistent pain have been fully explored.

Implantable pain therapy incorporates:

·         intrathecal morphine infusion and other analgesic infusions (also known as intraspinal pumps)

·         neurostimulation techniques such as:

·         spinal cord stimulation

·         subcutaneous electrical stimulation

·         peripheral nerve stimulation

·         deep brain stimulation

·         motor cortex stimulation

·         other implanted neurostimulation devices for pain.

  • Medical practitioner services

The Act includes in the definition of a ‘medical service’, attendance, examination or treatment of any kind by a registered medical practitioner.

Note: WorkSafe does not consider it a reasonable cost to pay for the following:

·         letters of advice

·         the issue of repeat prescriptions when the patient is not in attendance

·         post mortem examinations

·         issuing of death certificate.

WorkSafe will not pay medical practitioners for telephone consultations, either to the worker or other related parties such as the agent, employer or occupational rehabilitation provider.Which I think is disgusting!

  • Independent medical examinations

Read more about workcover IME in our previous posts (just enter the word IME in the search box)

  • MRI

WorkSafe will pay the reasonable cost of an MRI service in accordance with the WorkSafe fee schedule for a worker where the service is:

·         required as a result of a work related illness or injury

·         referred by a registered consultant physician or specialist

Read more about MRI’s under workers compensation here

  • Loss and grief counselling

WorkSafe can pay the reasonable cost of loss and grief counseling services at the request of a medical practitioner if those services are required as a result of a work-related injury or illness.

Note: WorkSafe will only pay for the reasonable costs of family counselling services that are incurred in Australia, provided by a medical practitioner, registered psychologist or social worker approved by WorkSafe and provided to families of workers who have:  died as a result of an injury or suffered a severe injury.

  • Naturopathy

WorkSafe can pay the reasonable cost of naturopathy services at the request of a medical practitioner if those services are required as a result of a work-related injury or illness.

  • Nursing

WorkSafe can pay the reasonable cost of nursing services at the request of a medical practitioner if those services are required as a result of a work-related injury or illness.

Nursing services are services rendered by a registered nurse, other than at a hospital or as a member of the nursing staff of a hospital.

  • Occupational rehabilitation including training courses & ergonomic equipment

Occupational rehabilitation (OR) services are offered to a worker with a current work capacity (CWC) or a potential CWC to assist them to RTW.

Workers are entitled to receive an OR service from an approved OR provider of their choice from a list of at least 3 OR providers.

There are different types of Occupational rehabilitation services: RTW with same employer; RTW with new employer. See the online’s claims manual for more information (under “return to work”section).

  • Occupational physiotherapy

Occupational physiotherapists are physiotherapists with specific skills and experience in treating clients/workers and can help facilitate early rehabilitation and safe and sustainable return to work. Occupational physiotherapists collaborate with the client/worker, their employer, medical practitioner and other health providers. This includes conducting worksite visits, developing and implementing return to work programs and writing certificates of capacity.

  • Optometry

WorkSafe considers optometry to be a primary contact service.

A referral from a medical practitioner is therefore not required for the provision of optometry services.

A referral is required from a medical practitioner for provision of any approved health service with the exception of medical, physiotherapy, osteopathic, chiropractic, optometry, dental and podiatry services.

  • Osteopathy

WorkSafe considers osteopathy to be a primary contact service. Therefore a referral from a medical practitioner is not required.

  • Pain management programs

WorkSafe can pay the reasonable costs of Pain Management and Network PM Programs to assist workers in their rehabilitation of a work-related injury or illness.

Pain Management and Network PM Programs are multidisciplinary interventions which are designed to assist workers with musculoskeletal injuries and persistent pain to manage their condition and reduce the disability associated with their pain.

Pain Management and Network Pain Management Programs also aim to assist workers who are having difficulties: managing their injuries and participating in functional activities at home, work or in the community due to their pain or reducing their dependency on medications and allied health treatment due to their persistent pain.

A written referral from a medical practitioner can be sent directly to a Pain Management or Network PM Programs provider.  The agent will then consider the request for a PM or Network PM Programs assessment

  • Pharmacy

WorkSafe will not pay for medications and pharmacy items that:

·         do not relate to a work related injury or illness

·         are not provided on the request of a registered medical practitioner or registered dentist

·         are not provided by a registered pharmacist

·         are not provided at a reasonable cost

·         are prescribed as part of a clinical trial

·         were required prior to the worker-related injury or illness

·         are not invoiced according to WorkSafe minimum invoicing requirements

·         are not registered on the ARTG (except glucosamine).

Read more about medication entitlements under workcover in our previous post

  • Physiotherapy

WorkSafe considers physiotherapy to be a primary contact service. A referral from a medical practitioner is therefore not required for the physiotherapy services.

WorkSafe will also consider the reasonable cost of Gym and swimming program.

  • Podiatry

WorkSafe considers podiatry to be a primary contact service.

A referral from a medical practitioner is therefore not required for the provision of podiatry services.

  • Private hospitals

WorkSafe can pay the reasonable costs of private hospital services required as a result of a work related injury or illness.

Written approval is required from the agent prior to the provision of the service.

Note: Prior approval is not required for requests relating to emergency psychiatric inpatient treatment. If a hospital seeks prior approval, this must not be delayed.

A private hospital is a private hospital:

·         within the meaning of the Health Services Act 1988 or section 178 of the Health Act 1958

·         within the meaning of a law of another State or of a Territory

or

·         outside Australia if approved by WorkSafe.

A private hospital service means the provision by a private hospital of:

·         maintenance, attendance and treatment

·         nursing care and treatment

·         medicines, medical, surgical and other curative materials, appliances or apparatus

·         any other usual or necessary services provided by a hospital with respect to the treatment of the injury or illness of a worker.

  • Psychology

WorkSafe considers psychology to be a referral service. A referral from a medical practitioner must therefore be provided prior to commencement of psychology services.

  • Remedial massage

WorkSafe can pay the reasonable cost of remedial massage services at the request of a medical practitioner if those services are required as a result of a work-related injury or illness.

Remedial massage is defined as the application of manual massage techniques to treat musculoskeletal disorders or dysfunctions in a systematic way. Remedial massage is designed to improve the function of the injured worker in the rehabilitation process and achieve progress in return to work outcomes.

  • Removalist costs

WorkSafe can pay the reasonable cost of removalist services at the request of a medical practitioner if the worker is required to move as a direct result of a work-related injury or illness.

In order for WorkSafe to consider payment of the reasonable costs of removalist services the agent must be provided with the following information:

·  a current referral from a medical practitioner

·  at least two from quotes from removalist companies.

  • Respite care

Respite care services are services provided to assist workers with a work-related injury or illness who are being cared for at their place of residence (eg by family or household members) by giving workers and carers a short term break from their regular support routine. Respite care can be provided within a worker’s place of residence (e.g. by an attendant carer) or externally (e.g. accommodation facility such as an aged care facility, supported residential services, shared community housing, or a day program).

Respite care services are intended to assist the continuation of the primary informal support relationship between a carer and an injured worker whilst giving both the opportunity to rest and have a break.

To be eligible for consideration of respite care services, a worker as a result of their injury or illness must:

·  have substantial physical, psychological, cognitive or sensory disability which was sustained as a result of a work related injury or illness

·  require a significant level of ongoing daily/personal support (For example: hygiene, mobility, supervision etc)

·  have a family or household member who provides to the worker a significant level of ongoing daily/personal support

·  have been assessed by an occupational therapist and/or multi-disciplinary team, as requiring respite care.

A referral is required from a medical practitioner.

  • Social work

WorkSafe can pay the reasonable cost of social work services at the request of a medical practitioner if those services are required as a result of a work-related injury or illness.

WorkSafe considers social work to be referred service. A worker can access a referred service with a medical practitioner referral.

  • Speech pathology

WorkSafe can pay the reasonable cost of speech pathology services at the request of a medical practitioner if those services are required as a result of a work-related injury or illness.

WorkSafe considers speech pathology to be a referred service. A worker can access a referred service with a medical practitioner referral.

  • Travel expenses

WorkSafe can reimburse reasonable travel expenses incurred by a worker to attend medical and hospital services (this also includes physio, psychologist etc) required as a result of a work-related injury or illness in accordance with s99 of the Act. Travel and associated expenses incurred to attend an independent medical examination, impairment assessment or Medical Panel assessment can also be reimbursed as well as Conciliation (ACCS).

Requests for reimbursement must be submitted within six months of the date of travel.

Taxi travel is also possible, I will discuss this in a later post.

Medication entitlements under work cover

What medication is covered by workcover

WorkCover will pay the reasonable costs of medication prescribed by a doctor to treat your work injury or illness.

WorkCover will also reimburse over-the-counter medications (eg, paracetamol for pain relief) and other non-medication items (eg, bandages for wounds) that have been recommended by a medical expert to help you recover from your work injury or illness. (Note, a medical expert is a doctor, dentist, psychologist, optician, physiotherapist, chiropractor, podiatrist, occupational therapist, speech pathologist or osteopath.)

Did you know?

Many pharmacies will allow you to “bulk bill” your medications – that is you won’t have to pay for them upfront as the pharmacy will directly bill the workcover insurance!

Stop paying for your medications (it all adds up quickly) and stop waiting for the reimbursement of medications you purchased (it often takes yonks to be reimbursed!)

What pharmacy items does WorkCover  not  pay for?

WorkCover does not pay for pharmacy items that:

  • your doctor did not prescribe  (in the case of prescription medicines)
  • your doctor  or  other medical expert (such as your physiotherapist) did not recommend (in the case of nonprescription items). This sadly means that you also need an approval to buy some bandaids!
  • you  take f or injuries/illnesses not related to your work injury/illness
  • those prescribed as part of a clinical trial.
  • WorkCover will also not pay for pharmacy items where proof of purchase and other relevant details are not supplied – hence you’re far better off having your pharmacist bill workcover directly for all medications!

If your case manager (who is NOT a medically trained person) is unsure whether an item you are claiming can be reimbursed, they will ask you or your practitioner for further information if you are lucky. Usually you will just get some nasty little letter saying that medication A is not appropriate for your condition and will not be paid for.

True example:

I had been diagnosed with severe CRPS (Chronic Regional Pain Syndrome) of a limb (in addition to a severe injury to that limb). My pain specialist (read: an anesthetist who is specialised in the management and treatment of pain) prescribed an antidepressant as part of the medication for my CRPS. Well this (very uneducated) case manager sent me several letters stating that antidepressant X was not appropriate and had nothing to do with pain control. Yeah right… Here we go again… Many antidepressants are used effectively for the purpose of pain management/control. I.e some nerve injuries respond very well to antidepressants, as does CRPS and certain types of arthritis.

If the case manager finds the items are for your work injury they will reimburse the cost (which often takes long) however if they are not for your work injury they will not reimburse the cost. Please note, if you do not agree with the decision you are entitled to challenge it.

Am I entitled to reimbursement of nonPBS (private prescription) medications?

Yes. Your doctor should be prescribing PBS medications when clinically appropriate for treating your injury, but some medications are not in the PBS schedule or are eligible for the PBS subsidy for certain conditions only. In this case your doctor will write a private patient prescription and WorkCover will reimburse you the full cost of your medicine.

If however, a medication is available on the PBS and does meet the indications listed in the PBS schedule, and your doctor has written a private prescription without apparent reason, your case manager SHOULD ask you to get a PBS prescription from your doctor if further doses of this medication are required – and not simply REF– USE to pay for that prescription.

True example:

My medical practitioner had been prescribing Endone (Morphine) for several months on a private prescription. After about 6 months, I suddenly was told by my frustrated pharmacist that “they” (workcover) sent him a letter (of which I of course never got a copy,nor my prescriber) stating that the Endone would no longer be paid for as it had to be prescribed on PBS. How am I supposed to know this? In any case I was left high and dry for it was Friday afternoon when I ran out of my Endone and needed an urgent refill… I was not allowed to get the precription filled and was sent home for -what became a terrible- long weekend without any morphine tablets. Thank you very much again for making me suffer even more ):

Can I substitute my prescribed medication for another brand?

Yes you can!

How am I reimbursed for pharmacy items?

If you pay for pharmacy items yourself you must submit a completed Pharmacy items reimbursement form (a receipt that you get from your pharmacist) as soon as possible to your case manager and attach itemised receipts.

You are required to sign this form to verify the pharmacy item is related to your work injury or illness. Your case manager can give you copies of the reimbursement form or you can download it from www.workcover.com.

Case managers can make allowances for workers seeking reimbursement for pharmacy items at the beginning of a claim without having  a completed Pharmacy items reimbursement form.

You must attach each receipt to the reimbursement form.  The receipt must list:

  • date and place of purchase
  • item(s)  name
  • quantity,  strength
  • cost.

WorkCover will accept handwritten receipts from the pharmacy if the pharmacy cannot provide you with a cash register receipt.

If details are missing from the receipt or the reimbursement form, your case manager may ask you for additional information before reimbursing you if you are lucky – usually they will just NOT reimburse you.

Note:

You do not need to submit a Pharmacy items reimbursement form for hospital-related items (as from the Hospital pharmacy). Simply send the hospital pharmacy’s statement they provide you to your case manager.

Do I have to pay for the pharmacy items up front?

As mentioned earlier many pharmacies will happily create an account for workers and directly invoice the case manager, which means you do not have to pay for the cost of the items upfront. In this case, you do not need to submit a Pharmacy item reimbursement form but you may still receive so-called “enquiries” (to put it gently) from your case manager if they are unsure an item is related to your work injury.

You are far better of to set up an account at your pharmacy, so you don’t have to pay for medication. It all adds up very quickly and,if you’ve been incapacitated for a while,you will soon realise how poor you are and counting pennies is the only way to survive.

Request for MRI under workers compensation

What is a Magnetic Resonance Imaging (MRI)?

Magnetic Resonance Imaging (MRI) is a radiological investigation to create cross- sectional images of the body.  These detailed clear images are used by medical practitioners to diagnose and investigate a range of conditions.

An MRI service requires a referral and consists of imaging, reading and providing a written report by a radiologist.

 

Referral for an MRI from a surgeon, registered consultant physician or specialist

If your surgeon, consultant or specialists refers you for an MRI, you do not need prior approval from work cover (your case manager) for the MRI.

However, some Radiology facilities (i.e. Olympic Park Imaging) will require an approval letter from workcover for any MRI, even if it has been prescribed by your surgeon or specialist.

In this case, simply ask your work cover case manager to write you a letter addressed to the Radiology facility, stating that the MRI has been approved and will be paid for by work cover. Your case manager should be able to do this immediately. However, make sure you tell (or write/email) your case manager in “child language” what it is you are after (because they don’t understand plain English!)

Example (true story):

My surgeon referred me for an MRI. I sent the MRI request form (from my surgeon) through to my case manager and asked her for a letter of approval stating that the radiology department had requested one and will not undertake any MRIs without a letter from work cover, detailing that the MRI has been approved and will be paid for. After a few days I did not hear back from my case manager. My GP, whom I happened to visit a few days later, wrote a letter to my case manager, stating that my surgeon had requested an MRI and could she please ensure prompt approval as I was in great pain. This letter was faxed to my case manager, again with the request to provide me with a simple letter for the radiology department. Well, about 3 weeks (!!!) later I contacted my case manager and her Team Leader and told them that I was still waiting for that letter for the radiology department. They told me that the request for the MRI needed to be reviewed by their in-house doctor before making a decision whether or not they would approve the MRI  (- which was requested by my surgeon, and made urgent by my GP-). A few days later (we’re now waiting 25 days) my GP tells me he had been contacted by the work cover insurance ‘house doctor’ to discuss the need for the MRI!

28 Days after having sent the urgent referral from my treating surgeon to my case manager, I finally obtained that 2 line letter for the radiology clinic, stating that the MRI had been approved and would be paid for by work cover.

My case manager insisted she had 28 days time… in-spite of me writing to her that I would hold her personally liable for any additional damage I would sustain and that I would rely on our correspondence in a court of law.

NO- she did not!!! An MRI requested by a surgeon does NOT need prior approval ! Needless to say how frustrated we (me and my surgeon) were. Imagine, you are in f***** agony, have done some serious damage to a body part, your treating surgeon and your GP feel that you need an urgent MRI, and they make you wait (inappropriately) for nearly 1 month before writing a 2-line letter! WTF!

What is wrong with these people? Are they illiterate? Are they just trying to wear you down until you give up? Or are they plain stupid?

Extract of WorkSafe’s policy regarding MRI’s

Is prior approval required for an MRI service? An injured worker may be referred for an MRI service by a consultant physician or specialist recognised for this purpose by the Commonwealth Health Insurance Act (1973). In these cases prior approval from a WorkSafe Agent is not required. It is recommended that the referring consultant physician or specialist contact the WorkSafe Agent to confirm that their patient has an accepted claim and that the region to be scanned correlates with the region of the accepted injury.

Read WorkSafe’s Policy here

Request for an MRI by your treating GP

WorkSafe will consider a request for an MRI service by a treating medical practitioner other than a consultant physician or specialist, where access to consultant physicians or specialists is limited and provision of the service would be expedited by a referral from the treating medical practitioner.  In these cases prior approval by the WorkSafe Agent is required.  The treating medical practitioner should provide a written request that includes a working diagnosis, an outline of examination findings and a clinical rationale for the MRI service.  A medical practitioner at the WorkSafe Agent will review these requests on a case by case basis.

I would love to hear about your stories!

 

 

How to obtain household help or home help under workcover

If you are no longer capable of doing house work (or your share of the house work),you are entitled to household/home help under workcover.

In order to obtain your household/home help you first need to visit your medical practitioner (i.e. your GP will do) and discuss those needs with him/her.

Your medical practitioner will have to write a letter to your work cover insurance (your case manager) and request household/home help.

Of course, and as usual, workcover (i.e. your workcover insurance company/your case manager) will make it very difficult for you to obtain the necessary help.

Tip

Get your Medical Practitioner to write in his/her letter the reason(s) why you need home help – that is: he/she needs to detail the “clinical justification“. It doesn’t matter if you have a gigantic medical file with workcover, hundreds of medical reports detailing your incapacity/impairment or plenty of supportive ‘evidence’. They will still need the “clinical justification” from your doctor before they will consider approving a home help assessment!

For example (true story): my GP agreed with my need for household help and wrote a brief letter to my case manager stating something along the lines (hey- here’s trying to stay anonymous!) “… the worker has a severely painful and severely unstable joint…needs house hold help as part of her/his medical treatment…”. This is NOT sufficient!

According  my case manager there was/is  “no clinical justification” that I need home help! Wow!  So, obviously the words ‘SEVERELY PAINFUL’ and ‘SEVERELY UNSTABLE JOINT’  do not fall under ‘clinical justification’! Maybe we (workcover victims) should send a pair of magnifying glasses and a dictionary to our case manager with each medical request 😉

So,basically, your medical practitioner (who is very busy and has to deal yet again with an enormous amount of unpaid paperwork!) needs to write in his request for home help letter the specific details why you need the home help. Think of it like a letter addressed to a 6 year old , for example: “… has a severely painful and severely unstable joint…needs home help.. BECA– USE when she/he tries to mop the floor her/his joint comes out of its socket (as in dislocates), following which he/she is in even more severe pain and following which more damage is incurred to the already damaged joint…”. Don’t laugh, this is  a TRUE story!

Only when there is “clinical justification”, your case manager will approve a home help assessment.

 

Your workcover insurance agent / case manager will then refer you to XXX  for a home help assessment and they do not need to provide  you with a choice of three service providers for these assessments!
(i.e. you do get 3 choice providers  for Occupational Rehabilitation). So it doesn’t matter who they send to your home to undertake the ‘assessment’, you have no say and must cooperate.  Bear in mind that workcover will always have the cheapest contracts with the worst possible companies/people…
Anyway, I recently had my home help “assessment” and I believe that in our next meeting, I will need to “try out various mops, vacuum cleaners, brooms and whatnot” – hey they want you to be “independent” after all (read NOT pay for a cleaner or gardener). It doesn’t matter to them if you can’t even write – you just have to try to mop your own floor, even if this means that you have to crawl on all four and lick the floor!
I will keep you posted on how the “trial” went 😉
Share your stories here!!!