Talking about medical approvals: IWSN’s next meeting with the government

IWSN Regular meeting with Workcover. Date of Meeting: 1 March.

This is the legislation:

WORKERS COMPENSATION ACT 1987 - SECT 60

Compensation for cost of medical or hospital treatment and rehabilitation etc

(1) If, as a result of an injury received by a worker, it is reasonably necessary that:

(a) any medical or related treatment (other than domestic assistance) be given, or

(b) any hospital treatment be given, or

(c) any ambulance service be provided, or

(d) any workplace rehabilitation service be provided,

And:

WORKPLACE INJURY MANAGEMENT AND WORKERS COMPENSATION ACT 1998 - SECT 279

Liability to be accepted within 21 days

279 Liability to be accepted within 21 days

(1) Within 21 days after a claim for medical expenses compensation is made the person on whom the claim is made must determine the claim by accepting or disputing liability.

Note : Section 283 makes failure to comply with this section an offence. Section 74 requires notice of a dispute to be given.

As you can see if you are injured at work and have had your claim accepted the insurer is required to pay for all medical expenses relating to your recovery. But those claims are treated separate from your actual claim (it in effect becomes another type of “claim”) and the insurer has 21 days to accept or deny liability for those medical expenses.

We don’t think this is acceptable. We continually hear stories from members that a reasonable claim has been denied by insurers and are constantly hearing stories that the current process is taking longer than 21 days.

Here’s a common example.

Injured Worker A has a psychological claim accepted. Their doctor puts in a request for ongoing counselling from a psychologist.

The first six sessions were approved within the 21 day period, the psychologist put in a new claim for a further 20 sessions given the PTSD Injured Worker A is living with (day 1).

The insurer sends a letter to injured worker A for a treatment review with the insurers Medical specialist (an injury management consultant) (day 15) which happens 2 weeks after the 21 day period is up (day 35).

The Injury Management Consultant provides their report a week later (day 42) and the insurer sends another letter to Injured Worker A denying liability for the further 20 sessions (day 42).

The injured worker then contacts their solicitor (day 43) and the solicitor puts in a request for a payment of legal expenses to WIRO to run a Medical dispute at the Workers Compensation Commission (day 45).

WIRO responds a few days later (day 47) agreeing to an independent medical specialist report for Injured Worker A before proceeding to the commission. The Injured Workers appointment with the solicitor’s Independent medical specialist occurs three weeks later (day 68).

Paper work goes into the commission from Injured Worker A’s solicitor (day 75) and the insurer who responds a week later (day 82).

A commission date is set for conciliation three weeks later (day 103) where a decision for 10 more sessions is agreed upon by all parties. The insurer sends a letter to Injured Worker A confirming this two weeks later (day 117) and the next ten sessions start a week after that (day 124).

That is a break in treatment of 124 days with the added stress on Injured Worker A of having to go through that adversarial process.

Another briefer example.

Injured worker B need physiotherapy after the screws comes off their broken leg. The Surgeon puts in the request at the same time this happens (day 1) – a follow up from a previous letter from the surgeon which foreshadowed the need for physiotherapy at the time the surgery was approved by the insurer. The insurer takes two weeks to approve the physiotherapy (day 14)

– quicker than the first example yes, but that’s two weeks in which Injured Worker B isn’t receiving physio despite the insurer knowing that physio was required straight after the screws came out of Injured worker B’s legs.

The legislation allows insurers to delay treatment for 21 days each and every time a request is made.

The legislation doesn’t prevent them from being more efficient than this. It’s the insurers who cause the delays- not the legislation. So why does it take so long to approve medical treatment?

We are going to talk to the Regulator and the insurer about this problem and need your help. Please fill out this survey and let us know what your experience has been.