Many legitimate seriously injured workers have their workcover benefits denied in full or in part. We actually wonder why this happens. Are injured worker’s workcover benefits denied or deflated as part of the workcover insurance companies bureaucracy or ‘actuarial’ tactic? As in a sheer numbers game? Let’s explore the main mechanisms behind workcover claim denials.
Workcover Claim denial – the processes behind denials
Once an injured worker files a workcover (workers’ compensation) claim, they will often become entangled in a protracted workcover insurance process, and they will be drowning in paperwork. Many workcover insurance companies routinely delay, deny and delay some more workers’ comp claims. They are quite a few reasons as to why so many genuine workcover claims are delayed and denied.
1.Workcover insurance company Case Managers
It is a fact that workcover insurance companies’ case managers (aka claims managers or claims officers or claim assessors) have strict targets to meet, and not meeting these key performance indicators (KPIs) can mean losing their jobs. This is one reason as to why so many legitimate workcover claims are denied in the first place. In a way it is quite simple to understand: if one workcover case manager approves, let’s say, 80% of workcover claims which are assigned to him/her, but the average approval rate by the workcover insurance company is 45%, that case manager will be flagged and concerns will be raised by management. They may well ask themselves what it is that this particular workcover case manager is doing differently than the other case managers. In other words: if certain set targets are not met, or are out of proportion with the averages, then that particular workcover insurer case manager will be in trouble.
You see, approving too many workcover claims affects an insurance company’s financial bottom line, in other words: their profits, and the profits to their shareholders. Therefore we can assume that the primary reason for the denial of a workcover claim is financial, and not necessarily that the workcover insurer does not believe that a worker has sustained a legitimate work injury.
Did you know that the reason why injured workers frequently get a different workcover case manager allocated is precisely for that reason! It is to make the process of denial non-personal. If a case manager cannot ‘get to know’ (or ‘bond’) with an injured worker, injured workers become mere numbers, not humans.
2.Workcover insurance in house medical assessors
One of the main steps taken towards workcover claim denial or medical treatment denial is the use of the dreaded workcover insurance company’s doctor. In fact, all starts with a paper review of an injured worker’s medical diagnosis, medical treatment plan and other insurer documents undertaken by an insurance doctor. They are often called in-house medical advisors. The fact that the assessment is made without even meeting the injured worker, or speaking with the injured worker, and without a physical and/or psychological examination of the injured worker again makes it much easier for the medical advisor to deny or deflate any legitimate workcover claim.
While we could accept the merits of a ‘paper review’ by a workcover insurance company’s doctor in cases of minor and obvious injuries, such as a fractured bone; we truly believe that the paper review practice is very unfair when it comes to more serious injuries. Too many genuinely seriously injured workers are wrongfully denied their claim, medical treatment or other benefits because of this common practice.
3.Independent medical examination or second opinion insurance medical examination (IME)
This is probably the biggest hurdle and roadblock to obtaining legitimate workcover benefits. Independent medical examinations are initiated by the workcover insurance company and used as an alleged impartial ‘ 2nd opinion’. These medical examinations are carried out by workcover insurers hand-picked doctors (and at times, other professionals such as rehabbers, vocational assessors etc.). Often the cherry-picked IME doctor will not have any expertise in the field of the injured worker’s injury either (eg. they will send complex orthopaedic injury for assessment by a general surgeon and not an orthopaedic surgeon). It is well known that many medical opinions and treatment plans from the injured worker’s own treating doctors and specialists are frequently negated or invalidated. Many workcover IME doctors will seek other reasons (any reason) for the injured worker’s injury, often with pre-injury, degenerative (old age) and/or psychological factors cited as the cause of the injured worker’s injuries/condition.
Too many of these workcover independent medical doctors, or health report sellers, are only too happy to write their assessment reports in favour of the workcover insurance company because insurance work pays! It pays much more than what they earn doing private work. Unfortunately, there are too many ‘rogue’ IME doctors who are more than willing to accommodate a workcover insurance company’s denial outcome despite knowing that the injured worker’s claim is completely legitimate and that their health is at risk. Not many doctors with a moral and ethical compass work as IMEs, or if they do, they simply don’t last because the insurers will not refer work to them.
Injured workers are up against a system that is primarily focused on producing IME reports to deny or reduce injured workers’ workcover benefits. Injured workers don’t only have to repeatedly face pro-workcover insurance company independent medical doctors but also have to face and fight a corrupt world of sub-contracted IME examination centres or IME ‘mills’. It has been alleged that some IME reports are routinely altered and doctored by the IME mills. An injured worker recently reported that his case involved two entirely different IME reports signed by the same IME doctor! When he managed to get a copy of the IME reports, it allegedly showed that the IME mill filled out the IME report. The actual IME doctor was handed the almost complete ‘report’ and only needed to add comments is a separate section and sign. This was allegedly done to ‘lighten the workload of the IME doctor’. Meaning that the actual IME doctor no longer needed to ‘waste time on reading background material on the injured worker’ before writing a full and final report. That way the IME mills can continue to focus on volume – the more IME reports they can churn out, the more profit they make! Needless to say that this practice could well result in the IME doctor – who does not have all the information – accepting a pre-written IME report at face value and signing off on it, even though it may have been concocted and or doctored. In other words, if the particular IME doctor was reasonably impartial, the company s/he works for (the IME mill) may well be truly partial with the workcover insurer.
It is perplexing that workcover insurance companies think nothing of paying thousands of dollars to IME doctors to deny injured workers’ legitimate benefits.