Obtaining prompt and proper medical treatment under workcover has become a virtual nightmare and, literally, a hit and miss with what is getting approved by the workcover insurer and what is not. The following article contains some tips on how to ensure your medical treatment is paid by your workcover insurance company.
Medical treatment under workcover – literally a matter of hit and miss
The workcover system is extremely one-sided in favour of the workers’ compensation insurance companies
1. As many injured workers know, the workers’ comp insurance companies cherry-pick the independent medical doctors, as well as the rehab service providers and other bedfellows…thereby weeding out ‘injured workers-friendly’ doctors, rehabbers etc. We also know from the VIC Ombudsman final report that this is pretty much standard practice, and the Ombudsman even found out that some of those IME doctors are nicknamed “Good for Termination”.
2. It is unfortunate but when injured at work, all the injured worker’s medical and like treatment requested by injured worker’s own treating doctors and even top specialists have to be approved by some workcover insurer case manager for “internal cost review”. This includes MRI, surgery, even basic physiotherapy and medication…and if not approved…injured workers simply don’t receive their prompt and necessary medical and like treatment. At least, not without a fight. This process alone, we believe, has rendered thousands of injured workers permanently impaired.
3. The injured worker’s requested and denied medical and like treatment are reviewed by either workcover in-house medical ‘advisor’ or an independent medical doctor (IME). It has been alleged that some of those in-house medical advisors are not even licensed or registered doctors. Also, these “doctors” have never met the injured worker either.
4. Some injured worker’s treating doctors and top specialists, in their utter frustration in not being able to get proper and timely medical treatment for their patients sometimes:
- declare the injured workers as having reached maximum medical recovery (MMI) so they get a chance at settling their workcover claims and can then obtain some of the medical treatment that has been denied to them
- encourage injured workers who are fortunate enough to have private health care, to simply have their injuries treated under private care, and not to mention that their injuries are work-related
- encourage injured workers to attend public emergency department in order to obtain prompt medical treatment, including surgery where necessary, and tell the injured worker not to mention the injury was work-related
5. WorkSafe VIC states on its website that they prefer that the injured worker’s healthcare provider invoices the injured worker’s employer or his/her WorkSafe agent (workcover insurer) directly. WorkSafe VIC will only pay for the approved cost of treatment.
If as, an injured worker, you choose to pay an account at the time of the service, then you should be reimbursed within 30 days from the time your WorkSafe agent receives your receipt. You need to send your receipts to your employer or workcover insurer within six months of the treatment.
Payment of the reasonable costs of medical and like services does not necessarily mean payment of the full costs. In some cases, there may be a gap between what the provider charges and what WorkSafe (workcover insurer) will pay.
It is easier said than done, for many workcover case managers will deliberately ‘misplace’ your invoices or allege that they were never received. They will drag this process out until the 6 months period (VIC) has passed and then claim you were too late in submitting your invoices and cannot be reimbursed.
6. Many injured workers are left with a broken body, permanently impaired and without enough money to fix their injuries on their own, or even pay for their own medications. If an injured worker mentions they were injured at work, even a public hospital – let alone a Private Healthcare Fund, will require the workcover insurer to actually pay for any medical treatment. The latter often starts a lengthy battle with the workcover insurer. Denials, delays, bureaucracy, independent medical doctors, disputes, endless waiting and worsening injuries as well as a lower chance of successfully returning to work.
Obtaining medical treatment when injured at work
Obtaining prompt medical care under workcover becomes a Catch 22, you’re damned if you mention that you were injured at work, you’re damned if you did not mention your injury is work-related.
We cannot stress this enough. If you fail to tell the medical providers, a Public or Private Hospital how your injury occurred and that it occurred while you were at work, you could be seriously harming your workers’ comp claim from a legal standpoint.
This could prevent you from getting the medical treatment that you need, such as reimbursement of out of pocket expenses such as medication, physio, consultation fees, medical imaging as well as obtaining medical treatment in the future. It is really important to provide as much detail about your injury and the fact that it is work-related to protect your claim for benefits to your medical treaters.
When the workers’ comp insurance company is investigating a workcover claim, they take statements from the injured worker and any witnesses. They also look at and scrutinise the injured worker’s medical records. They are looking to see what information is in the medical records, including the injured worker’s accounts of how and where the injury occurred. They will also read and review the medical records to determine which body parts the injured worker reported to the doctor as being injured. For this reason, when you talk to any doctor or any medical provider be clear and detailed when describing the nature of your injuries and how they occurred. Always identify where you were hurt, how the injury occurred and if there was anything unusual that caused your injury. Do this every time you see a new doctor or medical provider. This is particularly important when you are first seen after your injury and during the appointments in the first days, weeks, and months after the injury. However, it continues to remain important throughout the life of your workcover claim.
It is quite common for a workcover insurance company to either deny the injured worker’s claim completely or deny medical treatment wholly or to a specific body part. One of the biggest obstacles reported by injured workers is the finding by the workcover insurance company that the accident or injury was not reported in the medical records until several weeks or months after the initial date of injury and was not reported at the first date of treatment. Workcover agents read these records. If the injury, body part or the fact that it occurred at work is not in the medical records, they will often use that as a reason to deny the workcover claim, or medical treatment or fail to compensate the injured worker.
If it becomes necessary for your case to go Court, the medical records are often the most important evidence that will be used. When the injured worker’s medical records are being evaluated, they are given a great amount of weight as they are written by a third party (a treating doctor) that has no vested interest in the workcover claim.
Be careful after a workcover settlement
As a side-note, but an important one: some injured workers (including myself) have been on workcover for years and years, some over a decade. Once a workcover claim settles and in cases where medical care continues for life (as part of the settlement), some injured workers will be so sick and tired of dealing with workcover, that they will start paying for their own medication and/or treatment. Just for the sake of getting a break. Unfortunately, we have found out the hard way that if you pay for your treatment yourself, after settlement, and then, for example, require major surgery and contact your workcover insurance company, they will actually ask you to explain the gap in treatment! So, even after settlement (if you are lucky enough to reach settlement and lucky enough to have an agreement for medical and like treatment for the rest of your life), try not to take a ‘breather’ from the nightmare (workcover), but keep in touch with your workcover case manager, submit your invoices or- better- have your treaters bill your workcover insurer directly. Or else, you may have to ‘face the music’ and ‘explain the gap in your treatment’!
In other words, if after spending a decade or so in the workers’ comp system, clinging onto your sanity (or what’s left of it), and desperately in need ‘time out’ from that sick system, you will get punished for taking time out! Funny, not? And so it is that many of us, seriously injured workers, remain prisoners for life of a frustrating, insulting, bastardised (and more!) workcover system!
Our Australian workcover system is absolutely stonewalling getting adequate and timely medical treatment. How ironic, for the workcover system’s primary goal is to ensure injured workers can be ‘restored’ and return to work!