*The contents in this blog relates to legislation in Queensland.
Workers compensation can be one of the biggest blessings in one of the hardest times for workers. Nonetheless, managing the claims process whilst seeking treatment can often be an overwhelming and frustrating experience, without the right support.
In this article, we have set out three ways in which a treating medical team can be involved in assisting an injured worker throughout the claim process, to minimise stress and maximise access to treatment.
Application for compensation
Did you know that your general practitioner or treating specialist can lodge your Workcover claim for you?
Moreover, whether or not an application for compensation is accepted by Workcover (or a self-insured employer) largely and almost always depends on the medical evidence provided to the claims manager.
By way of context, Workcover, in assessing claims, has two criteria:
- Has the worker sustained an “injury” in accordance with that definition set out in the Workers Compensation and Rehabilitation Act (WCRA)? And:
- Has the injury arisen out of or in the course of the worker’s employment?
Evidently, the first question can only be answered by a registered medical practitioner – not a claims manager from Workcover; however, it is often usual for Workcover to also seek the doctor’s opinion as to the second criteria too.
Where a worker has effectively liaised with their doctor about the circumstances or events causing the injury, the claims process can be fast-tracked and accepted, sometimes even without considerable corroboration by the worker’s employer.
Administration – payment for reasonable medical expenses
Section 210 of the WCRA, provides, “that the insurer (Workcover) must pay the costs of medical treatment or hospitalisation that the insurer considers reasonable, having regard to the worker’s injury.” While on the surface, this provision appears to leave the decision up to a worker’s claims manager at Workcover, as to what treatment will be approved or disapproved, the real question as to whether your treatment costs should be paid, is whether they are “reasonable”.
Who can answer the question of whether treatment is reasonable? Your doctor. And if not your doctor, then an independent doctor arranged by Workcover.
If a recommendation for treatment comes from a registered medical practitioner and that treatment is necessary for the treatment or management of the work-related injury, Workcover must fund it accordingly.
In this way, doctors, specialists and allied health can liaise directly with Workcover and greatly assist in the administration of a worker’s compensation statutory claim.
The worker’s treatment team can promote better health outcomes
At various points in a statutory claim, Workcover will seek to wrap up or end a compensation claim. In these circumstances, a worker’s treating medical team are their best source of assistance in terms of maintaining both access to necessary treatment and maintain weekly compensation until it is medically safe to cease workers compensation benefits.
Your Workcover claims manager has one goal – to get an injured worker back to work and finalise a Workcover claim as soon as possible. A worker’s medical team on the other hand, also have one goal – to get a worker back to health in the safest way possible.
Balancing these competing interests, can be difficult particularly when a claim’s manager is pushing gently, but often firmly, to get a worker back to their place of employment, but the treating doctors feel the worker would benefit from further treatment to better their condition in the long-run. Which one therefore trumps the other – the insurer or the medical practitioner? The answer – the medical practitioner.
Sections 144A and 144B of the WCRA, provide, that the entitlement of a worker to weekly payments of compensation and the entitlement of a worker to payment of medical treatment/ hospitalisation or other expenses ceases when… “the incapacity because of the work-related injury stops,” and “medical treatment by a registered person is no longer required for the management of the injury because the injury is not likely to improve with further medical treatment or hospitalisation.”
Accordingly, unless a worker has been receiving Workcover payments for 5 years, or reaches the maximum amount allowed by the Act, the question of whether a worker is ready to return to work or wrap up their claim is entirely a medical question and one in which Workcover does not have the power to override. In that regard, a worker’s treating medical team, can insist on further treatment being provided, so that the claim and treatment can continue.
If you have sustained an injury in the course of your employment in Queensland, we recommend that you get legal advice but you should also contact your doctor directly about lodging a Workcover application at the earliest opportunity. Your GP or other treating specialist can not only lodge the application for compensation for you, but can set up a treatment plan ready to be paid by Workcover, as soon as the application is accepted.
Secondly, it is vitally important that you remain in regular contact with your treating doctor throughout the course of the claim to ensure your interests are being protected. Your doctor can assist greatly, where they believe you have a reasonable prospect of recovery through further or better treatment.
Finally, when the time comes for your claim to end, or for you to attempt to return to work, your doctor’s opinion is determinative as to whether that is a reasonable or appropriate option for you at that time. As stated above – the question of whether you are ready for that step is medical and not solely at the discretion of your claims manager!