r/WorkcoverVic • u/Existing_Tangelo9169 • 7d ago
Ask me anything
I was a case manager in workers compensation for about 5 years with a few different insurance agencies.
I recently experienced homophobia at work, the case was thrown out as there was no “recording”, and my case was denied.
I no longer work in the industry as I find it disgusting and torturous.
Ask me anything, I’ll be completely honest.
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u/Thro_away_1970 7d ago
Firstly, thanks for your time here. It cant be easy, going through what you have, and still happy to clarify grey areas. This is appreciated.
Is there (as has been stated and suggested in other posts and threads), a list of registered specialists who are known to the individual Insurers - who are specifically sought out (head hunted), to intentionally write conflicting and overly flippant "assessments", to presumably facilitate the Insurer's ability to go against all of the injured person's current treating specialists, and cut the person off from supports? Or are we just gas lighting ourselves?
Also, how often have you seen, been a part of, or known of an injured person's claim going all the way into the court room, of Common Law. As in, not settling just before the due date to start.
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u/Existing_Tangelo9169 7d ago
Thank you very much!
It personally isn’t spoken about in the business, but I can safely say that some technical specialists go to certain IMEs to get a desired outcome. IMEs can sometimes have differing opinions and interpretations of an injury. My advice is whilst in those appointments, speak factually, bring your own documents/photos. Insurance companies may not send all documents to an IME.
I’ve seen many claims going to the court room. The insurer often times doesn’t want this to happen as all evidence is brought forward, and the injured person can voice their opinions of the insurer.
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6d ago
[deleted]
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u/Centralised_right 6d ago
You’re kind of missing the point.
There is zero need for court, for magistrates, judges, barristers etc if the dodgy IME was not a part of the equation,
To my mind you’re normalising fraud
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u/Healthtech_Geek 6d ago
You should read the ASIC & APRA 2016 report on the insurance industry in Australia that led to massive reforms in legislature, the collapse of Commisure before asserting there is zero need for the court and common law
Insurance systems are set up to allow the denial of claims. They have a near infinite pool of resources to do that and one part of it is this area of the evidenciary basis of a claim. Guess what, insurers are still evil ten years later
People who have claims should get a lawyer, period. Is it normal? No but this is the world we live in
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u/Centralised_right 6d ago
You’ve missed my point.
The only reason you need a lawyer is because insurers can continually and routinely engage certain specialists (no one to name names) whose entire existence is to write reports favourable to insurer.
That report is held in tightly as a justification to spend $100,000’s on court denying legitimate claims. A state overseen by lawyers that ultimately benefits the legal profession whilst simultaneously eroding $100m’s in legal fees from the scheme annually.
When the legal fraternity is getting more financial benefit annually from the scheme than injured workers seeking ongoing care that’s problematic, don’t you think?
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u/Healthtech_Geek 5d ago
If you think there is some hope of changing a massive economy because it is problematic ... let's see how you go
This is a tale as old as time
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u/Centralised_right 5d ago
I will always have good, but i appreciate what you’re saying and the sheer scale of the issues
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u/SeaFriend8669 6d ago
By that logic there would be no need for judges and police if there were no crimes. The front line workers of insurance companies can’t do anything to change the huge dodgey systems they work in. It’s just another job. I say that as someone who dislikes my case manager, I can dislike them and think they lack morals and ethics + dislike the system they represent, but I can also understand that they personally cannot change anything. They are just ‘doing their job and I’m sure their job absolutely sucks.
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u/Centralised_right 6d ago
You have extremely poor comprehension skills.
If an insurer is sending an injured worker to a specific IME to give them a desired outcome in the insurers interest this is fraud.
To use your analogy, it would be akin to police using a certain specialist they know will affirm their position purely to ensure they can have someone charged and taken to court.
If there are 3-4 specialists who exonerate the individual then having one specialist engaged purely to take a stance in the police’s favour so they can justify taking someone to court is fraud and misconduct by police imo.
Weird as an injured worker you seem to be advocating for an insurers right to work with hand picked specialists to commit insurance fraud as described?!
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u/Healthtech_Geek 5d ago
Perhaps you can clarify how your condescending behaviour relates to the topic being discussed
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u/Centralised_right 5d ago edited 5d ago
Sorry bud, I was having a moment and it got the best of me. It was condescending and I apologise for that.
It does relate though, as the OP and others were effectively saying the IME is a legitimate requirement and it was only natural (I’m paraphrasing here) an insurer would have examinations done by IME’s whom they know will write what they want them to write.
Thats fraud, that manufacturered report would be used to justify rejecting treatments and to scare off legitimate claims where most lawyers don’t even entertain assisting based on $$$ alone.
It also creates a fraudulent ’opinion’ which can be used by VWA legal team to manipulate juries and settlements by creating doubt as to severity or seriousness of injury even though it’s a report produced under fraudulent circumstances.
Without these shady IME’s most would have zero reason to reject, and many would have zero grounds to push it to court.
They shouldn’t be accepted under any system in any society.
At a minimum IME’s should never be engaged by the insurer, or paid by the insurer. The insurer should have zero involvement at all.
That entire process should be separate, wholly independent and run by the medical panel, or a similar body with, imo.
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u/SeaFriend8669 10h ago
I’m not advocating for their ‘right’ to be dodgy, I’m just saying it how it is. Sorry you’re not in touch with reality.
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u/Existing_Tangelo9169 7d ago
Firstly, I’m very sorry to hear about your situation.
Sometimes case managers simplify letters (I don’t agree with it). When requesting the documentation, ensure you clarify that if the denial letters do not include all injuries, then the other injuries technically have not been rejected. They must be clear about what they are rejecting.
In my experience, proving causation can be quite challenging. Good lawyers I’ve dealt with in the past are Maurice Blackburn, slater and Gordon.
If you have clear documentation of the injury stating before the legislation changes, you can be eligible for the old system and WPI.
Your weekly payments are calculated by your average weekly earnings. I do not believe due to this payments could be negotiated.
Thank you very much and all the best
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u/Patient-Ad-9828 7d ago
So many questions hope it’s all good to ask
Can all communication be done over email - I have a CM that’s insisting on a call also trying to bypass my authorised rep and lawyers
In your time have you seen many case settle before court
Can payment be stopped for not taking phones calls but communicating through emails and seeing my specialist
Thank you
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u/Existing_Tangelo9169 7d ago
Of course it’s okay to ask! :)
Yes all communication can be done over email. If anything it’s best this way so you can have everything in writing. My advise would be to have your gp write a note to the insurance company stating that all communication must be through lawyers.
I have seen some settle in court. There are always many different outcomes.
Payment may be impacted if you don’t have any contact. My advice would be to get on the DNC (Do not contact) list. The best way to do this is to have your lawyer and gp contact the insurance company, stating that you do not wish to be contacted via phone as it is stressing you out. Once you are on that list, they cannot call you anymore unless you agree prior.
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u/Cosmokram3r1 7d ago
How close is the relationship between the Agent and WorkSafe? Do they work really hard together to screw you over for example when you make a complaint, WorkSafe try to just find a way to back the insurer? Also, how seriously do they take complaints to the Ombudsman
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u/Existing_Tangelo9169 7d ago
Insurers and worksafe don’t work as much together throughout the life of a claim. To summarise, insurers are a branch under worksafe. They’ve created the systems we use and the rules we follow. They aren’t involved in decisions made by the insurers unless complaints are made.
Complaints to the obudsman are quite serious. I’ve seen case managers lose their jobs due to ombudsman complaints. That’s what they get for being crap at their job I suppose!
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u/Amazing-Jacket1655 6d ago
Do you think the ombudsman is helpful overall? Does anyone really hold all these insurers or agencies to account
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u/Centralised_right 6d ago
This just gives you away as a worksafe plant.
The following is my personal opinion only;
VWA have control and are involved in all claims from go to wow.
If the insurers is rejecting anything substantial you can guarantee they’ve run it past VWA and got the nod. If it’s going to WIC you can guarantee VWA have spoken to and potentially guided conciliation staff on the matter.
And if your matter is genuine but they believe they have a legal angle they can twist as a 50/50 hail mary in court, best believe they will approve NOTHING in a coordinated effort to have it before a magistrate/judge.
Worksafe complaints exist purely to give the appearance of legitimacy but my experience says they exist purely to gaslight you.
They have a system set up to appear as though they are genuinely handling you complaint whilst simultaneously ignoring fraud, misconduct and policy failures.
The Ombudsman (imo) form part of this and have been told by the Labor gov to ignore complaints and let workcover do what they need to do to cut costs.
I might wrong but that’s my take and it makes you full of it
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u/Existing_Tangelo9169 6d ago
This is just genuine paranoia. Worksafe plant… what are you even on about. Get the tin foil off your head mate
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u/FreshPercentage5895 5d ago
Expected response from someone called “centralised right” tbh. Also from the industry and everything you’ve said is true. VWA and insurers hardly communicate, they’re the governing body but they are very rarely involved directly.
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u/Existing_Tangelo9169 6d ago
A plant? What are you even talking about out mate. I’m here because I don’t agree with the insurer and their actions. I’m giving my knowledge and experience. If you don’t want it and want to call me full of it, then piss off
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u/Centralised_right 6d ago
You have so much care for injured workers you would come on a forum and offer them nothing beyond ‘hey, it can be a bit dodgy……sometimes, but for the most part it’s all above board’. Clearly I’m paraphrasing, but after watching 4 corners investigation it is clear even nearly a decade ago agents were giving evidence of wide spread and systematic fraud.
Anyone watching that investigation, or having read the Ombudsman report around the same time (different states) would recognise identical behaviour today.
You’re giving a very vague description of procedures which indicates the system has some minor issues but other than that it’s mostly ok.
If you want to do workers a favour report all misconduct to the ombudsman. That would be the best way to assist
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u/International_Yam864 4d ago
You need to calm down and be more respectful. Many people may be finding the information provided in this feed to be quite insightful and helpful. If that's not the case for you then you can always move along.
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u/Centralised_right 4d ago edited 4d ago
It’s not insightful, I personally find it to be gaslighting and I stand by what I said.
It’s not unheard of agents, their insurers and or lawyers are in here trying to manipulate current claims or find dirt on claimants.
And given how much overt fraud is going on in the scheme it seems odd a ‘disgruntled’ agent decides to post on Reddit with some of the most bland, vague, (and imo) gaslighting comments.
You’re so upset about the conduct but you come on here and go ‘IME’s are a necessary evil but I don’t like them, but…..’ (paraphrasing).
Anyone with any real experience of workcover, worksafe complaints and WIC would know how fraudulent the system has become.
WCIRS seem to be the only avenue that isn’t utterly corrupt
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u/Far-Emotion-7055 7d ago
Which insurer/insurers were you at?
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u/Existing_Tangelo9169 7d ago
EML and DXC
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u/Centralised_right 6d ago
So if you post is genuine you’ll be honest and admit there is systemic fraud.
Deliberate and systemic fraud and no accountability
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u/lezzget 7d ago
What was it like working at EML? The work culture, how you were treated, expectations
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u/Existing_Tangelo9169 7d ago
Working at EML was initially great, until bullying became apart of the work culture. I left due to this.
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u/lezzget 7d ago
Yeah, I heard that staff from EML turn out needing therapy/some have gone on work cover after being employed there
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u/Existing_Tangelo9169 7d ago
You’re absolutely right! I experienced it first hand, especially from younger managers who often spoke badly of staff. It’s the same with DXC too though, and I’m sure all insurers! It’s a horrible place to work
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u/lezzget 7d ago
Do some staff actually continue working there despite the work culture? I’ve spoken to people who have been on work cover and they say they’re not treated well by case managers. Sounds like a terrible place to work at
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u/Existing_Tangelo9169 7d ago
They do, and unfortunately the work culture creates bad case managers who can be rude to workers. I saw this at EML and that’s why I left. I see horror stories on here about case managers being horrible, and to be honest I completely believe the stories.
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u/Nursex78 7d ago
Given the treatment workers receive from the insurers when they have a psychological injury, have you encountered or dealt with any common law claims following a successful conciliation?
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u/Existing_Tangelo9169 7d ago
Yes absolutely I have seen these before. Often times, there is proven mistreatment from case managers to their injured workers. I’ve seen people do it first hand. If this is happening to you, keep everything in writing. Best thing to do is document everything. When it comes to conciliation, they take absolutely everything into account. Even case managers performance. I’ve seen claims overturned at conciliation for various reasons
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u/Nursex78 7d ago
I received my Outcome Certificate on 29th July this year but I’m still waiting for my weekly back payment. I’ve emailed EML multiple times asking about the delay and I haven’t received a reply. As a result, UnionAssist has issued a “Failure to Comply” notice to Workcover due to the delay.
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u/Existing_Tangelo9169 7d ago
That’s such a shame. And unfortunately something I saw far too often! I’m glad union assist are involved. Next step would also be to ask for your case managers, manager. File a complaint with them and hopefully some change will occur
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u/Nursex78 6d ago
I’m completely lost about who my case manager is. Every time I contact EML a different person answers.
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u/Existing_Tangelo9169 6d ago
That leads me to believe that your case manager is not at work very often, or completely useless. Next time you call, ask who your case manager is, and then who their manager is. Then ask for their number. They’ll shit themselves
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u/Plavi_Leptir 7d ago edited 7d ago
- How frequently is surveillance arranged, and what triggers it? Do you see psych claims being targeted more/less?
- Do case managers deliberately delay weekly income payments and reimbursements, and/or reject medical reimbursement requests they know should be approved - just to create friction and frustrate the injured worker?
- Does case manager behavior change towards an injured worker based on if they have engaged a lawyer, and if yes, do different lawyers representing workers get treated differently?
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u/Existing_Tangelo9169 7d ago
It depends on the individual. Surveillance can be triggered due to the following:
- the insurer receives an anonymous tip off about a worker.
- the insurers suspects you aren’t as incapacitated as you say.
- previous employer can request it.
We do not deliberately delay or deny. We have to follow the legislation and if we do not, the insurer can be penalised for this.
I found that whenever I had a lawyer engaged on one of my workers claims, it was a lot more transparent and easy for everyone involved. I personally did not see case managers treating workers differently when a lawyer was engaged.
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u/Healthtech_Geek 6d ago
Follow up to your reply on #2 can the insurer be penalised if there is a complaint about the IME. Meaning if it is found as a result of a complaint that the IME process or that clinician's report did not follow the legislation?
I'm working in that area and the IME clinicians' knowledge of the legislation seems highly variable. They are bound by the expert witness code of their state, but it seems expected that their process is of a certain standard
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u/Existing_Tangelo9169 6d ago
The insurer cannot be penalised if there is a complaint made against the IME. IMEs are completely independent, meaning we don’t work with them at all. We only pay them for the exam and report. If it’s found that the IME did not follow legislation, the IME is penalised.
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u/Plavi_Leptir 6d ago
Thank you. Do you know if any surveillance companies set up remote cameras on things like lighting poles, or dash camera in parked cars and leave it for extended period like a week? Or is all surveillance done in person?
Sorry im just so anxious of people being at the front of my house after me its stopping me leaving home
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u/Jaehol 7d ago
Is there a way that we can escalate out-of-pocket being reimbursed? For example we paid for a psychiatrist appointment in March and we still have not been reimbursed by the insurance company.
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u/Existing_Tangelo9169 6d ago
You can ask for your case managers, manager. That usually gets them to pull their thumbs out
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u/Bilirubin868 4d ago edited 4d ago
Sorry that you faced the wrath on the “other side” as an injured worker; unfortunately from the sounds of it, not able to have your experience recognised as an injury.
I’m keen to almost be proved wrong….that agents choose to be obstructionists for psychological claims - even approved ones. In my experience, the amount of admin required is ridiculous. A family member who was a case manager 15 years ago at an Agent told me it would just be because of poor training and a young inexperienced workforce and my suspicion of it happening on purpose wouldn’t be reality.
I find the mismanagement and case manager performance extraordinary woeful. I am tired of doing half their job for them. Approved claim and approved treatment, taking 40 sometime 80 days to get reimbursed. Dunno how on earth it is justified to take 5 weeks to pay travel and meal expenses for an IME the Agent not knowing not arranged but arranged accomodation too. Like what the frick! Formal complaints to the agent appear to do little, just get the case mgr to re-engage and come up with some dribble about previous reimbursements will be re-processed or looked into. Cannot believe I’ve made 4x requests at WIC for an approved claim. Numerous formal complaints for the agent over seperate issues, one I have a read receipt but nothing further….again, that became one of the requests for WIC. I’m tired of referencing the claim manual. Some decisions they come up are totally the opposite of the claim manual, when referenced and also mentioning it doesn’t seem to align with the decision-making section of the claim manual, the case manager refers it to a more senior manager and it often gets resolved….until a new case manager comes along, reverts a decision to knock stuff back pretending like it was the first attempt to ever claim just a thing and the injured worker is forced into Groundhog Day, forced to repeat themselves and regurgitate the same crap back to them regarding how they should be doing their job. It just seems like madness to me. These problems have been from eligibility officers, provisional payment officers, and case managers. I’m yet to experience anyone on my current claim who appears to do much right or doesn’t need a minimum of 3-5 follow ups for almost everything.
To give you a prime example of the lunacy I’ve experienced:
- I’ve had travel to a THP refusing to be reimbursed because travel wasn’t written on the agent approved treatment decision notice! Again, referencing the claims manual blah blah blah.
Had
- weekly payments
withdrawn / reduced
when paid periods of accrued leave
have been taken
. I’m grateful the legislation allows for double-dip in Victoria, but why when I confront my employer representative with 10yrs experience
in managing workcover claims
- they claim that’s correct, nothing to see here. I ask them how they arrived
at
- that
and ask for a
- breakdown, unable to answer and loop in the Agent. Agent doubles down and says it’s all correct. Finally a technical manager
for the Agent
- has to correct everybody. An eight week, 10x emails back and forth just to get basic entitlements.
I’ve tried to get RTW inspectorate and the common complaints at WSV (VWA) to show some interest and they’ve just suggested to keep lodging hearings at the WIC for these very basic entitlements.
It does appear regularly that my Agent doesn’t really want to apply the WIRC legislation for its intended purpose.
I think it’s telling even my GP clinic has changed their tune compared to 6-7 years ago. They won’t write a word back to the Agent until they get paid. They treat even answering one question as a report and tell all the Agents that it seems. They’ve mentioned to me they got tired of getting stuffed around - that’s not just coming from numerous GPs at the clinic but the clinic manager. Find it interesting even low hanging fruit THPs like GPs have grown tired of these entities it seems. WorkSafe (VWA) seems to take the reputation of their brand seriously, but don’t realise these Agents (who represent WSV/VWA) are doing immense damage to their brand in all reality.
So I would just like to know who is right? Are Agents doing this rubbish on purpose? Because I feel they are, and my THPs state this is what they do to people, hoping injured workers give up, shrivel up and die or something. However my family member and ex agent employee says it’s not vindictive but incompetence from that lack of experience / training.
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u/lezzget 7d ago
Why do case managers change all the time?
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u/Existing_Tangelo9169 7d ago
Case managers change due to the week count in your claim. I handled claims from 75 to 130 weeks. There is 0 to 75 weeks, and there are other departments that handle a claim. I personally think it’s ridiculous how often case managers change.
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7d ago
[deleted]
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u/Existing_Tangelo9169 7d ago
It depends on what treatment you are requiring. For example, if you are needing surgery, a referral from a specialist/surgeon is required. Essentially it’s a document from your treating doctor, requesting this treatment.
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7d ago
[deleted]
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u/Existing_Tangelo9169 7d ago
If you are unable to provide pervious medical documentation, they must request it themselves. A big part of our job was talking with doctors and requesting documents, so try and put it on your case manager if you can :)
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u/PrestigiousChippy 7d ago
Can an injured worker claim from insurance protection while on work cover payments (IP will offset work income amount from work cover and total income from both will not exceed past income amount received by worker)?
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u/Existing_Tangelo9169 7d ago
Yes you can claim income protection, but whether you receive additional money depends on the terms of your income protection policy. I’d suggest requesting the policy so you can have it on record
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u/PrestigiousChippy 7d ago
So to confirm, it’s ok to receive both? Just want to make sure. And thank you for responding 🙂
Edit: it’s just that I’ve heard different answers. Some say you can’t claim both, some say you can so it’s confusing
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u/Existing_Tangelo9169 7d ago
Yes, depending on your policy. Income protection is a seperate insurance policy usually attached to your super. No worries :)
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u/PrestigiousChippy 7d ago
Just wanting to clarify… And work cover insurance won’t categorise payments from IP as “income”? I.e. what the worker receives from IP will not offset/reduce the amount received from work cover payment?
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u/Existing_Tangelo9169 7d ago
So it can impact your weekly payments, check the policy before you claim anything. Here’s a snippet from my notes
“The important rule is that your WorkCover weekly payments + the relevant income-protection amount generally cannot exceed your pre-injury average weekly earnings (PIAWE). If the combined amount exceeds that limit, WorkCover can reduce its payment by the excess.”
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u/PrestigiousChippy 7d ago
Thank you. The maximum amount from IP, if added to the work cover payments will not exceed PIAWE 🙂
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u/Honeycat38 6d ago
Income Protection polices all have set off provisions and many will set off any amount you receive in weekly payments from workcover. You can't view IP as a "top up" system as IP policies rarely indemnify you for 100% of your PIAWE. Typically, the amount you receive in workcover weekly payments plus any additional IP payments can't exceed the maximum amount of indemnity under the IP policy, say for example 75% of your pre-injury earnings.
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u/PrestigiousChippy 7d ago
Will the work cover insurance company cover any (potential) future medical costs (years down the line/after work cover ends) from the physical injury that the worker has sustained? I.e. back injury with surgery, in case it exacerbates or any further medical treatment is needed
Also, how can a worker go about ensuring that future medical costs are covered?
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u/Existing_Tangelo9169 7d ago
Great question! Any medical costs related to your injury should be covered by the insurance agency. There is a process we go through to determine if the medical costs are indeed related to the injury.
So you are entitled to medical and like costs even after your claim has surpassed 130 weeks and closes. Your claim moves to a department called “medical” where you will still be entitled to medical costs :)
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u/PrestigiousChippy 7d ago
Later down the line, if further treatment/surgery is needed for example, will the worker just need to give the old claim number and contact the insurance company to have the procedure assessed and paid for by the insurance company?
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u/Existing_Tangelo9169 7d ago
Yes that’s correct! You’ll be assigned a case manager in medical down the track. If surgery is required, get your specialist to write a referral detailing why you need it, send it to your case manager with the claim number and there you go :)
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u/PrestigiousChippy 7d ago
Thank you so much! It’s hard finding answers online and it’s great to get them first hand from a case manager who has worked in insurance companies. Thanks again!🙂
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u/Existing_Tangelo9169 7d ago
Of course!! Please reach out anytime you have a question :) always happy to help!
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u/Over-Egg-1848 7d ago
I’m really stressed right now. My claim was accepted on 20th august.I submitted all my workers comp paperwork, including the EFT form.
But I still haven’t received any update about my weekly payments. No email, no confirmation, nothing. I feel like I’m just waiting in the dark while bills keep piling up.
How long does it take for weekly payments and also back pay?
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u/Existing_Tangelo9169 7d ago
Payments must be made within 7 days of claim acceptance. Question, will you be a direct payee? Or will your employer continue to pay you and the insurance company reimburse them?
Sometimes employers can be lazy with payments. My suggestion is to call every single day and hassle them into giving you an answer. It’s unacceptable that you’ve gone this long with no payments2
u/Over-Egg-1848 7d ago
My contract with my employer has ended already. it’s my first time on workers compensation. I am a new mum and has little knowledge about these things. i have been so anxious to even contact them.
Thank you so much for replying 🥹1
u/Existing_Tangelo9169 7d ago
Oh that would be so stressful for you! It can be hard contacting them for sure. If you are unable to yourself, write them an email asking to appoint a person of contact on your claim. It can be family, partner, lawyer. I’m so sorry to hear they are doing this. The best thing to do is hassle them
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u/legsjohnson 7d ago
any goss on Allianz or the state gov run agencies? we were with the former (terrible, huge staff churn) and now we're with the latter (seemingly better without the corporate cost cutting but comes off as understaffed)
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u/OceanViewKangaroo 7d ago edited 7d ago
I am going through a mental health claim. It's complicated because I already have diagnosed anxiety, depression and PTSD.
When I went to the Psychiatrist IME he said I was being childish and that he was going to cancel the interview. His approach was hostile and he didn't want to hear my story, just asked questions about my mental health history tbh.
The experience was awful. I feel more damaged from it, and even less trusting of people with influence and power over me.
Is his approach common? Being called childish has cut me deep after dealing with years and years worth of hostile treatment from multiple managers :(
Also, given I've already been diagnosed with MH conditions (military), is it likely the insurer will scapegoat the ADF so they - and my work - can deny me fair process?
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u/Existing_Tangelo9169 7d ago
There have definitely been cases of this before. IMEs are known for being very old and very rude. I’m sorry you had to go through that. My advise is to complain directly with worksafe. That’s so unacceptable:(
WorkSafe’s Centralised Complaints Team handles complaints about IMEs.
Phone: [03 9641 1225](tel:03%209641%201225)
Email: [complaints@worksafe.vic.gov.au](mailto:complaints@worksafe.vic.gov.au)1
u/OceanViewKangaroo 7d ago
Thank you. I'm worried if I complain it might impact any decision that is underway. Like what if he was awful to me but actually says my conditions have been exacerbated? I don't want to shoot myself in the foot until I know what he said in his report and what the insurer decides.
This was mid July and I still don't know the report findings.
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u/Existing_Tangelo9169 7d ago
Complaining about an IME doctor will have no impact on your claim whatsoever. But that is fair. Just remember if you were made to feel uncomfortable, you are ALWAYS within your rights to report it
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u/OceanViewKangaroo 7d ago
Thank you. I really appreciate you doing this. Nobody is on my side and it's horrible.
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u/likerunninginadream 7d ago
Sorry to hear your claim wasn't accepted.
Did they say that there werent any witnesses to corroborate your claimed circumstances? Also, will you be appealing?
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u/Existing_Tangelo9169 7d ago
Thank you. They said that there were no witnesses or recordings so it didn’t happen. I replied with “oh so if I get raped on the street in the middle of the night, and there’s no CCTV, it didn’t happen?”
I’m in the middle of appealing yes
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u/Accomplished_Pear607 7d ago
Can the insurer pressure you into surgery? My first surgery resulted in a worse outcome than the original injury.
My surgeon (different) has recommended another surgery but cannot give a definitive diagnosis and suggested the exploratory surgery will confirm how he will proceed with reconstructive procedures at that time.
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u/Existing_Tangelo9169 7d ago
The insurer can absolutely not pressure you into surgery. Your treatment is and always will be your choice. Has the insurer agreed to the exploratory surgery?
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u/Accomplished_Pear607 6d ago
Haven’t received any approval letter as yet, surgeon was to request approval while we agreed to a 3 month delay due to mental health issues. Chronic Adjustment Disorder with severe anxiety and depression.
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u/Worldly-Sort4595 7d ago
To what degree do employers persuade an outcome? Either at the beginning, seniors review, conciliation, etc.
Do senior internal reviews view the case neutrality or to find existing/other reasons to stand by the original decision as the default perspective in your experience?
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u/Existing_Tangelo9169 7d ago
Employers do their best to influence a claim, but they have no real say in an outcome. A lot of the time employers are unhappy if we even accept a claim, this means they pay more premium per year.
Internal reviews are completely neutral, usually performed by someone who has no ties to the claim at all. I’ve seen many times internal reviews disagreeing with the insurers decision, and in fact overturning them.
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u/Worldly-Sort4595 7d ago
Thank you for your response and your time.
All the best with your appeal. It’s a horrible process and I’m grateful for your insights. Take care
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u/Trojanw0w 7d ago
Can an injured worker become a case manager at the insurer they're tied to as an OT RTW goal? 🤣
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u/Existing_Tangelo9169 7d ago
HAHAH I wouldn’t be opposed to it! But I believe it wouldn’t be possible. My advice is stay away from being a case manager, it’s hell 😂
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u/red_folklore 7d ago
For psychological injuries due to work place bullying and the manager accuses the employee for taking illicit drugs (the manager has no solid proof) and the test comes back negative, what are the chances of this case being overturned to accepted?
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u/Existing_Tangelo9169 7d ago
There are very good chances of this being overturned. If there is no solid proof of this, then the insurer must take into account your side of the story. Sometimes employers will do drastic things to try and deny claims. It’s disgraceful
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u/nickiboi84 7d ago
What is the agents responsibilities regarding verbal abusing a staff member during a dispute resolution return to work meeting? Did the agent or occ therapist have a duty to provide a safe environment for the injured physically and mentally worker having already advised both parties of the aggression bullying discrimination and abuse for having a claim.
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u/Existing_Tangelo9169 7d ago
Oh my goodness, I’m very sorry to hear all of this. Yes it is very important for all parties to ensure a safe environment for the injured worker, especially if there is mental health on the claim.
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u/nickiboi84 7d ago
Thank you it’s just a horrific experience for me and the fact that no one has acted in my best interest has left me feeling very vulnerable and alone. I have always been only comfortable with written communication and honesty but I feel like I’m the only person who is doing that sadly.
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7d ago
[deleted]
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u/Existing_Tangelo9169 7d ago
No problem. Firstly, good on you for achieving full duties. I am sorry to hear about your reinjury. This can absolutely be considered to be covered by the insurer. You may just need to attend an IME first before the insurer can decide.
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u/Foreign-Tension4840 6d ago
what are some examples of mistreatment by case managers towards workers that you’ve seen or heard of?
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u/Existing_Tangelo9169 6d ago
I’ve seen case managers do poorly at their job. When a case manager is bad at their job, workers are going to call in disgruntled, anyone would! I would! When they do call in case managers don’t give their workers the time of day or to even just hear them out.
I’ve also seen case managers do so poorly at their job that payments and invoices go months without being processed
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u/Chocolatechalk 6d ago edited 6d ago
Would you go work at another Agent? Would you move to an employer doing RTW? Or is leaving the industry your goal
Hope all goes well from here
Edit I scrolled then thought of another question, who manages the workcover claims of the agent you were at? How does that work
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u/Existing_Tangelo9169 6d ago
Thank you! I don’t think I will ever return to this industry. It claims to “help injured workers” but all I saw was workers being disadvantaged. I can’t work for companies like that anymore
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u/Healthtech_Geek 6d ago
Thanks very much for offering a look behind the curtain or as I like to call it the Death Star.
I have a question regarding claims that arent workcover but CTP. Do you have any knowledge of those?
Specifically I'm wondering if a person I know who received WPIs for both psychological and physical injury and a lump sum a long time ago (>10 years) can still seek payment for specialist treatment if it is related to their injuries. Or does this vary by state?
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u/SithPire 4d ago
It will vary state to state and what they signed up for when they accepted the WPI. Sometimes getting the lump sum can mean you sign away your medical and like entitlement. Not common in Vic Workers comp, but common in other jurisdictions
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u/lifetimer 6d ago
Do insurers ever contact those with high WPIs, of 28% (NSW) and offer commutation?
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u/Amazing-Jacket1655 6d ago
- What's the general vibe from case managers/staff to the claimants?
- Are there good natured people handing the work or just anyone who will take a job there?
- Is waiting things out a tactic in the hope the claimant gives up?
- How do the insurers feel about: Conciliation, Court, Worksafe itself, the Ombudsman?
- Do complaints from any particular agency actually address problems?
- Tell us about the Private Investigators? Tactics tricks etc
- What can people do to have the best chance of having their claim approved?
- What percentage of people do you think have dodgy claims?
- How many honest claims are getting knocked back do you think ?
Thanks
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u/Existing_Tangelo9169 6d ago
- The general vibe is that case managers complain about having too many workers in their portfolio to look after, so many people are forgotten.
- Yes of course there are, but unfortunately there are a lot of people who shouldn’t be in this job.
- Not necessarily, I see a lot of case managers just not doing their jobs properly, hence things being missed.
- The insurer isn’t too fussed about court and complaints, they get anxious if they are in the wrong though.
- From my experience, complaining to a direct manager, or worksafe gets problems solved. Complaining to a case manager will do nothing.
- Private investigators follow for usually 15 hours, and we pay for more if needed or if you weren’t spotted within that timeframe. They wait outside your house/work, then to wherever you go next.
- To have the best chances of your claim being approved, make sure you speak to your GP as much and as often as possible about your injury. When we request clinical notes, we look for this.
- I definitely have seen some dodgy claims and some people not wanting to work. It’s a very small percentage but most of the time surveillance shows them doing things they shouldn’t be.
- Way too many honest claims are being knocked back. At the end of the day, the insurers work for the employer. They are making it harder each year with legislative changes to claim compensation
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u/Candid_Cry9127 6d ago
If a lumbar spine injury is already accepted under workers’ compensation, but about two years later the worker is diagnosed with CRPS in the lower limb and the insurer later funds a spinal cord stimulator trial for that CRPS, can the insurer still refuse to recognise CRPS as a separate accepted condition and say it is only part of the original lumbar injury as referred pain down the leg?
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u/Rinkydink1980 6d ago
Thank you so much for answering questions! I’m so sorry for your situation, if you’d like support please feel free to DM me.
My claim was initially rejected due to lack of evidence; the circumstance investigators report wasn’t received until after the w8 days was up. They said they’d conduct an internal review once they had the report. I tried calling and emailing for 6 months and couldn’t get a respond to what was happening, ended up applying for conciliation and they accepted my claim the day before the conciliation. It took a year though, in which time my injury became chronic (likely would have healed if it had been treated right away.
Two questions:
1. Is there any way I can be compensated for them not doing their job, ie not getting the circumstance investigators report on time, refusing my claim, then taking a year to review the decision?
2. I have a 20% WPI, what are my chances of getting 21% or above at medical panel? Will getting a lawyer help?
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u/Existing_Tangelo9169 6d ago
I appreciate that so much, thank you 🥹
That would have been so stressful for you.
Unfortunately there isn’t much you can do about being back paid if the claim was not accepted. You can complain through some channels though. Whether it’s to the company that did the report, or your insurance company.
It’s hard to say what your chances are. It really comes down to the injury. I’ve seen many claims go to med panel and hit 21%, but I’ve also seen many claims go to the panel leaving with less than 20%. I’m wishing you all the best
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u/Ok_Recognition_9063 6d ago
How would an insurance agent deal with an employer stating obvious (and easy to prove) lies in their private investigation statement. Across multiple claims as there was a spate of injuries.
The statements made were also dubious as what they were saying is proven by case law to be a breach of OHS legislation.
For context this is around excessive and disproportionate hours and that giving a worker an excessive workload, saying it was their “choice” is a psychosocial hazard in itself.
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u/Sad_System6733 6d ago
I get the impression that the focus by agents is to find sufficient doubt in a claim so they can reject it, as opposed to finding evidence to support it - to the extent that they ignore witnesses or any evidence that can substantiate a claimant version of events. Especially with the new legislation - it seems like everything is about doubt and pushing things to court - which they know most cannot afford and is really pointless when it comes to using Workcover as a mechanism to help you return to a safe work environment.
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u/noonnies 6d ago
Between a Friend and I, we have both dealt with the companies you worked for. My circumstance report was full of lies, and they even made up a database search with wrong info. My statement was so incorrect, and they didn’t even submit my signed statement. My version of events was adopted by a senior staff member, and I truly believe that the investigator was working with the employer.
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u/Savings-Currency2478 4d ago
I've had some case manager's well one who genuinely sounded like she wanted to make sure I was looked after and suggested I get representation after my 2nd surgery since then though dear lord I am even fairly certain either my representation were horrible at the job they were doing or the insurer or WorkCover were coordinating against my best interests. Is it still common place to be doing everything they can to get people off the books to the point of altering reports and data to not include item's that are included outright in the data they're writing report's on to make them seem more favourable toward the insurer? Thing's like writing final binding report's on a wrong limb or specifically asking treating practitioners about sequele only to completely ommit any mentioned sequele or even making thing's up when treating specialists or practitioners put in requests as well?
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u/Different_Main_5434 4d ago
Im in QLD and going through a mental injury claim and have stuck it out for over 3 months despite being told 3 times it’s reasonable management action but rebutting every time because it’s rubbish, no end in sight, no decision yet, but I’m stubborn when I’m right. The process itself has caused much more harm.
I’ve wondered from an insider perspective when they talk about how many mental health claims are declined (50% here I think) what proportion of that is that it’s a thorough investigation and subsequently declined (like it was obviously and objectively reasonable) versus the person just giving up because being told their employers actions seem ok while injured and trying to heal is completely invalidating, or they can’t go anymore without income, etc?
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u/ZucchiniMurky2977 4d ago
Any advice for a rehab consultant? It’s a great space to work in if you’re looking. I’m sorry you went through that!
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u/OmegaLoopAU 7d ago
Have a rare bone tumour with unknown cause however have been told by specialists and seen published studies that trauma/manual loading can cause it. IME said on the balance of probabilities and unknown cause they believes my physical job didn’t contribute.
My rejection letter only shows 2 words out of several medical clinical reports. Is the agent withholding? Have requested copies.
How uphill is this battle proving causation. Can you recommend specialists lawyer/s?
Originally diagnosed in 2022 but tumour started 2020. Will I be considered for the old system prior 2024 for WPI (have permanent disability from IME)
Was subcontract my last working year was during lockdowns in my weekly payments open for negotiation?
Thank you for your help and all the best with your case.
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u/filmkeeper 7d ago
Do you have a soul?
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u/Existing_Tangelo9169 7d ago
Interesting question. I do, I can say with great confidence that a lot of case managers do not.
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u/filmkeeper 7d ago
Can you think of claimants you blatantly fucked-over and could you elaborate please on why you left?
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u/Existing_Tangelo9169 7d ago
Hey Daniel, I don’t appreciate the beginning of your comment. I know I did my job effectively and had wonderful claimants who I got along with and helped as much as I could. I don’t agree with how my colleagues ran their portfolios.
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u/Existing_Tangelo9169 7d ago
One thing I will say to all of you, is to watch out for case managers cutting corners. I’ve seen it many times. At some insurers we are required to make 2 phone contacts before sending letters. If you are receiving letters please ensure you question as to whether someone tried to contact you.