What to do when workcover medical treatment & surgery is denied

surgery-workcover

If you have a WorkCover claim, and the WorkCover insurer has made a decision that you don’t agree with, it is important that you know that you are allowed to challenge this decision. This can include denial of medical and like treatment, even denial of requested surgery. In this article you will find some useful resources to help speed up the decision-making process, as well as dispute and complaints avenues.

What to do when workcover medical treatment including surgery is denied by the Agent

Joe is currently challenging the (typical) denial of his requested elective shoulder replacement surgery, required after his workplace accident, and requested by one of the top Professors shoulder specialists in the country!

Let’s step you through the workcover VIC “process”:

Email from Case Manager (following aknowledgement of receipt of request for surgery), sent to both the injured worker and the surgeon.

 

It is important you know that the relevant workers compensation legislation (VIC) states that:

Within 10 working days of receiving the elective surgery request, the Agent will advise whether:

  1. the request has been approved
  2. the request has been denied
  3. further information is required to make a decision.

Where further information is required, the Agent will advise whether the elective surgery request has been approved or denied within 10 working days of receiving the additional information. (Also see policy for Elective Surgery, WorkSafe VIC)

In the above case, the injured worker’s case manager did NOT give a valid reason for the indecision as required under the relevant legislation, other than to state “the request is still under review with WorkSafe medical advisors”. (Interesting-WorkSafe Medical Advisors? We don’t think so as it will be an in-house (within the insurer/agent) “medical advisor” – probably not even an orthopeadic surgeon).

It is therefore important you reply by citing/referring to the relevant legislation as to speed up the decision-making process and avoid even more delays. When they know you know your rights and the law, they are less likely to mislead and deceive you!

Countless injured workers face ridiculous obstacles and unnecessary delays in obtaining rightful medical treatment, including surgery. In other words: It’s not uncommon for people who are injured and who are tight for money to be denied medical treatment while they wait on WorkCover’s approval, and the problem is that delays of medical treatment can often jeopardise a patient’s chances of recovery. Many injured workers have been crippled for life due to delayed medical treatment!

How to dispute denial of Medical Care

Reply to the Agent/WorkCover Case Manager

As explained above, the workcover insurer (Agent) has 10 working days to make a decision about a request for medical treatment and/or surgery. Should they require additional information, they have a further 10 working days to give you their decision on whether they accept or reject your request for medical or surgical treatment. (see below for Joe’s reply to the email of his case manager).

Conciliation

The Work Place Injury and Rehabilitation Act (VIC) states that if a worker disagrees with a decision made by the WorkCover insurer they can lodge a request for conciliation with the Accident Compensation Conciliation Service (ACCS) 

A request for conciliation generally needs to be lodged within 60 days of the insurer’s decision. Disputes that we often see include rejection of treatment request such as surgery or psychologist visits, even medication. But you first need a letter of denial/rejection.

The ACCS is an independent organisation whose role is to conciliate WorkCover disputes. You can find the relevant request for conciliation form here.

Whilst lawyers are precluded from attending the conciliation conference, you can request independent representation from WorkCover Assist, which are generally very good. This should be noted on the request for conciliation form.

The ACCS will then decide whether your surgery can be approved, or, more likely, refer the matter to a Medical Panel, and possibly a Court.

Needless to say that it can be a long, tedious and stressful process.

For many injured workers, the feeling of absence of hope and helplessness that arises from their severe pain, constant abuse from the  insurer, constant denials of even the most basic medical and other care or services, extreme financial distress and even the prospect of permanent disability may cause such prolonged periods of extreme stress and emotional turmoil.

Complaint options

If you have concerns about ‘service delivery’ issues (eg delayed/late payments or a failure to respond to you), you should first complain to the complaints department of the agent/self-insurer managing your claim. (ie. XChanging, Allianz, EML etc). If you are unable to resolve the issue within a reasonable period of time or there is a clear mistake, the Ombudsman (see below) may be able to assist you.

In addition to the above dispute resolution process, you are also entitled to make a complaint to WorkSafe and to the Victorian Ombudsman.

WorkSafe can take complaints about Independent Medical Examiners (IMEs) and Occupational Rehabilitation providers etc. Contact WorkSafe first and you may contact the Ombudsman if you are dissatisfied with WorkSafe’s handling of your concerns.  For more information about the Victorian Ombudsman visit their website.


Joe’s reply to case manager – can be used as a sample letter

Thank you for your update re the pending approval or denial of my surgeon’s requested elective [type of procedure] surgery.

I assume that the reason for the indecision to date is that you (the Agent’s “Medical Advisors”) “require further information”.

As per the relevant Vic Workers Comp legislation and WorkSafe’s Elective Surgery Policy, the Agent is required to provide one of three answers within 10 working days of receiving the elective surgery request.
1.the request has been approved
2. the request has been denied
3. further information is required to make a decision.
“Where further information is required the Agent will advise whether the elective surgery request has been approved or denied within 10 working days of receiving the additional information”.

I look forward hearing from you with the Agent’s final decision with regards to my specialist shoulder orthopeadic surgeon’s (Dr X) requested elective surgery within the required 10 working days.

As mentioned in my previous correspondence I would be more than happy to be assessed by any IME of your choice if this could in any way help or speed up the decision-making process.

As an important side note, could you please advice me what to do should I l[whatever emergency could occur due to the delay in surgery] Do I need pre-approval for emergency surgery?

Lastly, [removed] – ie. ask a copy of the orgican request for surgery, make it clear you will dispute a denial etc.

Kind Regards


Pre-written letter as used by workcover Agents to acknoledge receipt for requested surgery, and to ask for additional information

(insert).

(insert).

(insert).

(insert).

Dear (insert).

 

Request for more information

Your patient:                       (insert).

WorkSafe claim number:  (insert).

Employer:                           (insert).

 

I acknowledge receipt of your request for (insert)., for (insert). received on (insert)..  We need more information before we can make a decision about the surgery requested.

The role of (insert).

(insert). can pay the reasonable costs of elective surgery required as a result of a work-related injury or illness in accordance with Victorian workers’ compensation legislation.

 

OPTIONAL – USE PARAGRAPH BELOW ONLY IF REQUEST IS RECEIVED FROM AN INTERSTATE SURGEON.

WorkSafe Victoria’s publication, Reimbursement Rates for Medical Services, lists the maximum amount that WorkSafe Victoria (WorkSafe) will pay as reasonable costs for surgical procedures provided by medical practitioners.

Further information required

In line with WorkSafe’s Surgically Implanted Prostheses policy,  (insert). requires details of the prosthesis item code and anticipated cost (listed items are available from the Department of Health and Ageing).

 

Please complete the Surgery Request for Information form attached and fax or mail it to this office by (insert).. Please note that there is no fee payable for completion of this form.

 

Please note that gap-permitted or non-listed prostheses require prior approval from  (insert)..  Invoices for these items may be returned unpaid if prior approval has not been received.

What  (insert). will do

On receipt of this information, we will make a decision about whether we can pay the reasonable costs of (insert).’s surgery.  We will write to both you and (insert). notifying you of our decision within 10 working days of receipt of this additional information.

Where to get more information

If you would like more information on the WorkSafe Victoria Elective Surgery Policy please go to worksafe.vic.gov.au/policies and click on Elective Surgery.

 

OPTIONAL – USE PARAGRAPH BELOW ONLY IF REQUEST IS RECEIVED FROM AN INTERSTATE SURGEON.

To view WorkSafe’s Reimbursement Rates for Medical Services, go to worksafe.vic.gov.au/fees.

 

If you have any questions about this letter, please contact me on freecall (insert). or directly on (insert)..

Yours sincerely

(insert).

(insert).

Direct phone number: (insert).

Direct fax number: (insert).

(insert).

 

On behalf of WorkSafe Victoria,

a trading name of the Victorian WorkCover Authority

 

cc:         (insert).

 

Enc:       Surgery Request for Information form

 

Surgery Request for Information

AGENT TO COMPLETE IDENTIFYING AND CONTACT DETAILS BELOW

Attention                                (insert).

(insert).

(insert).

Direct fax number: (insert).

 

Your patient:                          (insert).

WorkSafe claim number:     (insert).

Employer:                              (insert).

 

DELETE OPTIONS IN THE TABLE THAT DO NOT APPLY.  DO NOT ADD ADDITIONAL OPTIONS- THIS WOULD CONSTITUTE REQUESTING A TREATERS’ REPORT AND WOULD ATTRACT A FEE.

Please complete the comments section of the table below

INFORMATION REQUIRED COMMENTS
Brief description of the specific surgery to be performed

 

 

 

 

 

 

Clinical indication for the elective surgery

 

 

 

 

 

 

If you are planning to use a gap-permitted or unlisted prosthesis, please detail the anticipated prosthesis details and written clinical justification for gap-permitted/unlisted prostheses (if required)

 

 

 

 

Medical practitioner name               ____________________________________

Medical practitioner signature        ____________________________________

Date completed                                 ____________________________________

 

 

We hope this helps a little to take some control!