Navigating the Claims Maze: Avoiding the Traps of Work Injury Claims
Updated: Jul 2
In this blog, I write about important aspects of managing a workplace injury, early intervention, the insurance process, and returning to work. My goal as a Counselling Psychologist is to support individuals achieve the best outcome. The best outcome is usually, where possible, returning to work and restoring an individual's preinjury functional status, as best as possible.
While an early return to work is in the interest of all parties, the employer's behaviour and the insurance process often act to exacerbate the impact of workplace injuries. The insurance process can be worse than the injury itself. Insurance companies have plenty of experience minimising their claims while the unsuspecting injured worker is thrown into a maze in which they have to survive. It is often like a long nightmare!
My interest in this area comes from thirty years of experience as a Counselling Psychologist, both working in and leading teams, in areas of allied health rehabilitation. Besides proactively rehabilitating clients with disabilities and injuries, I have also had the privilege of leading up to ninety allied health employees, where I learned important leadership skills to minimise injuries in the workplace and manage injuries from an employer perspective when they occurred.
Good, proactive management can minimise the impact of workplace injuries for both the employee and their family, as well as for the employer. Unfortunately, my experience has been that many employers lack the appropriate skills to manage workplace injuries, especially the psychological aspects, which are often the most important. I hope this blog helps both employers and employees navigate better through workplace injuries to achieve optimal outcomes for all parties.
Entering the Maze
Injury at work can be a traumatic and stressful experience, and the process of making an insurance claim can often feel overwhelming. With numerous legal and medical procedures to navigate, it can be easy to fall into the traps of the claim process and miss out on important entitlements.
This is where an experienced SIRA-accredited psychologist can provide invaluable support. By working with a psychologist, claimants who are injured at work can better avoid the traps of the claim process and ensure that their rights and entitlements are protected.
This blog will explore the various ways in which the right psychologist, who is informed about insurance processes, can help claimants navigate the claim process, manage their mental health and well-being, and achieve the best outcome possible.
Whether you are struggling to return to work, managing physical and emotional symptoms related to your injury, or simply feeling overwhelmed by the claims process, a psychologist can provide the support and guidance you need to successfully manage your injury and move forward with your life.
Why Consider Avoiding the Insurance Claim Process?
Sometimes workplace injuries occur as a result of bullying, poor management or substandard workplace culture. Leaving a job before an injury occurs, may be easier than making a claim for a workplace injury in some cases. This is because making a claim can involve a complex and time-consuming process. The process typically requires the collection of medical evidence, filling out forms and paperwork, and dealing with insurance companies, lawyers, and medical professionals. Often, claimants may also be required to attend medical assessments, undergo psychological tests, or attend court proceedings. This process can be overwhelming and stressful, especially for those who are also dealing with the physical and emotional effects of a workplace injury.
Additionally, there may be concerns about the impact of making a claim on the claimant's employment status, reputation, and future career prospects. Some claimants may also be concerned about the outcome of their claim, the length of time it takes to receive compensation, and the potential for the claim to be denied. Insurance companies will also often do whatever they can to minimise their liability. Don't expect any huge payouts as these days there are strict regulations around the way payments are calculated and caps on the maximum lump sum which are very modest compared to the arduous and stressful process to which claimants are subjected.
In contrast, leaving a job is often a more straightforward process, especially if the claimant has found alternative employment. However, it may also involve its own set of challenges, such as finding new employment, adjusting to a new workplace, and managing any financial impact of leaving a job. You will also lose accumulated sick leave and potentially long service leave. Having said that your health and ability to earn an income is an important priority.
Ultimately, both making a claim and leaving a job have their own unique challenges and it is important to carefully consider all options and seek appropriate support before making a decision. Ultimately, you want to make the best decision for yourself and limit the negative impact of any work experience. Moving on and leaving it all behind can have its benefits!
What is Early Intervention?
Early intervention is a proactive approach taken by employers to support an injured employee's return to work as soon as possible. It involves providing appropriate support, resources, and accommodations to help the employee recover from their injury and return to work in a safe and timely manner. If an employer has such a program in place, which is highly recommended, then they will usually require a medical certificate confirming the injury or illness.
Here are a few reasons why employers should offer early intervention:
Demonstrates support: Offering early intervention can go a long way to providing appropriate care for an employee. In return, they feel supported which helps build loyalty.
Improves employee satisfaction: Providing support and resources to employees during their recovery can improve employee satisfaction and help maintain positive relationships with employees. Improved satisfaction leads to better engagement which is often associated with higher productivity.
Increases productivity: By supporting employees to return to work quickly, early intervention can increase productivity and improve the overall functioning of the workplace.
Promotes recovery: Early intervention can promote the physical and mental recovery of injured employees, helping them to return to work faster.
Reduces cost: Early intervention can reduce the cost of workplace injuries, as prolonged absence from work can result in lost productivity and increased insurance premiums and compensation costs.
Legal compliance: Employers have a legal obligation to provide a safe working environment and to support employees who are injured at work. Failure to provide early intervention can result in legal consequences.
In conclusion, offering early intervention to employees who are injured can have numerous benefits for both the employee and the employer. It can promote recovery, reduce costs, improve employee satisfaction, increase productivity, and ensure legal compliance.
BEFORE YOU LODGE YOUR CLAIM
Should I Trust the Insurer?
Tread with caution. There are several reasons why some people may choose not to trust insurers when making a claim:
Complicated processes: Be prepared to enter the circus with a volley of complex forms, ongoing requests for information and bureaucratic processes.
Denied claims: Insurance companies may deny claims for various reasons, such as a lack of coverage, a technicality in the policy, or a dispute over the amount or nature of a claim. This is the insurer's first line of defence, so do not be surprised when they try to refuse your claim to avoid liability.
Lack of transparency: Insurance companies may not be transparent in their claims process or the basis for their decisions, which can be confusing and frustrating for policyholders. They are, however, obliged to be transparent so keep them accountable!
Unfair practices: Some insurance companies may engage in unfair practices, such as denying claims without proper investigation, or using misleading information to justify a denial.
Delays in processing: Insurance claims can take a long time to process, in fact, months to years, which can be frustrating for policyholders who are already dealing with an injury or damage to their property. The ongoing process can potentially exacerbate any damage to mental health caused by the original workplace experience.
Low settlements: Insurance companies may offer low settlements for claims, which can be disappointing for policyholders who expected a higher payout.
Remember, an insurer's priority is ultimately to limit their liability and support the financial interests of their shareholders. Let's be clear on that!
Common examples where insurers have misled claimants include:
Lack of information: Not advising claimants of the process and requirements so that their claim is jeopardised.
Incorrect advice: Telling the claimant to return to work when it contravenes their medical capacity stated on their current medical certificate.
Abuse of rights: Sending claimants for a psychological assessment without informing them of the reasons for the assessments or their rights.
Disrespecting rights: Failing to send a copy of psychological assessment results and reports to the claimant and their treating doctor.
Lack of transparency: Refusing to provide claimants and their treating health professionals copies of psychological assessments and reports.
Mismanagement: Ordering independent assessments of claimants when it is in contravention of policy and procedures.
Intrusive actions: Insurers often request full access to your medical records and then can use personal health information not related to the claim against you.
However, it is important to keep in mind that not all insurance companies are untrustworthy. Some insurance companies might have a reputation for fairness and transparency, and there are regulations in place to protect policyholders and claimants from unfair practices.
If a policyholder is concerned about an insurance claim, they may want to consider seeking the help of a solicitor or a consumer advocate to ensure their rights are protected.
ACCESS TO MEDICAL RECORDS
CAUTION: Giving Consent to Access Medical Records?
The first thing to ask is, 'Should I give blanket consent to an insurer to access all my medical records?'
It is generally not recommended to give blanket consent to an insurance company to access all your medical records. Medical records contain sensitive and personal information, and you should carefully consider the information that is being shared and why it is needed.
When making an insurance claim, you may be asked to provide access to specific medical records that are directly related to the injury or condition being claimed. This information can help the insurance company evaluate the claim and determine their liability and, if applicable, the appropriate benefits to be paid.
If an insurance company is asking for access to all of your medical records, you may want to ask for clarification on why this information is needed. You have the right to control the release of your medical information and to limit the scope of the information being shared.
In conclusion, before giving blanket consent to an insurance company to access all your medical records, it is important to understand the reasons for the request and to carefully consider the information being shared. If you are unsure, it may be a good idea to consult with a lawyer or other professional for advice.
Can Claimants and Health Professionals Object to Requests for Information?
Some health professionals do not realise that they have responsibilities to their clients, even when the client has given authority to the insurer to access information. Claimants and health professionals can object to information being requested by insurance companies. Both claimants and health professionals have a right to protect the privacy and confidentiality of personal and medical information. A health professional should always act in the interests of their client and avoid releasing information that is not relevant to the insurance matter.
Claimants have the right to control the release of their medical information, and they can object to the release of any information that they believe is unnecessary or could harm their privacy. They can also limit the scope of the information being shared, for example, by providing only the specific records that are directly related to the injury or condition being claimed.
Health professionals, such as doctors and registered health professionals, are also bound by ethical and legal obligations to protect the privacy and confidentiality of their patient's medical information. They can object to the release of any information that they believe is not necessary for the claims process or could harm their patients' privacy.
In conclusion, both claimants and health professionals can object to information being requested by insurance companies, and they have a right to protect the privacy and confidentiality of personal and medical information. If you have concerns about the information being requested, it may be a good idea to seek the advice of a lawyer or other professional.
Do Everything in Writing!
Protect yourself! Consider doing everything in writing! There are several reasons why it may be advantageous to conduct all communication in writing with insurers when making a claim:
Documentation: Written communication provides a record of the correspondence between the policyholder and the insurance company. This documentation can be useful if there is a dispute over the claim later on.
Clarity: Written communication can be clearer and more precise than verbal communication, which reduces the risk of misunderstandings or miscommunication.
Evidence: Written communication can serve as evidence in case of a dispute over the claim.
Consistency: Written communication helps ensure consistency in the information provided to the insurance company. This reduces the risk of conflicting or inconsistent information being provided, which can delay the claims process.
Accountability: Written communication creates a paper trail that holds both the policyholder, the insurance company and the claimant accountable. This can be useful if there are any disputes over the claim.
By conducting all communication in writing, policyholders and claimants can help ensure that their claims are handled efficiently and fairly. It can also provide peace of mind and help avoid misunderstandings that can lead to disputes and delays in the claims process.
Do be careful, however, about what information you put in writing. If in doubt, consult your legal representative before sending.
Obtain Medical Certificates for Time off Work!
Yes, if you have been injured at work and need time off, or are working at a reduced capacity, you need to obtain medical certificates. A medical certificate provides evidence of your injury and your need for time off work or reduced capacity. It is typically issued by a doctor or other medical professional and will indicate the nature of your injury, the expected duration of your absence, and whether you can perform certain tasks.
The medical certificate is often required by your employer and may also be used as evidence in your insurance claim. Obtaining regular medical certificates can also help to support your claim and ensure that you are receiving the benefits and entitlements under the terms of your insurance policy.
If you have continuous time off work due to an injury then ensure there are no gaps between your medical certificates.
What is Work Capacity?
Work capacity refers to an individual's ability to perform work-related tasks, including physical and mental demands. It is a measure of a person's capacity to perform their job safely and efficiently and is influenced by various factors such as physical fitness, skill level, experience, and overall health.
Work capacity is relevant in the context of injury management and return to work, as an individual's work capacity may be impacted by their injury. In these cases, it is important to determine the individual's current work capacity, identify any restrictions or limitations, and make appropriate accommodations to help them return to work safely.
Work capacity assessments can be performed by healthcare providers, occupational therapists, or other specialists and typically involve a physical examination and evaluation of the individual's ability to perform work-related tasks. The results of the assessment can be used to develop a return-to-work plan that is tailored to the individual's needs and capabilities.
When considering work capacity, ensure that psychological injuries, barriers and necessary workplace adjustments are considered in the return to work plan. The psychological aspects of a workplace injury can be overlooked and are equally important in achieving a successful return to work.
In conclusion, work capacity is a measure of an individual's ability to perform work-related tasks and is an important factor in injury management and return to work. Assessing an individual's work capacity, including psychological aspects, can help ensure a safe and successful return to work.
Do Not Exceed Your Work Capacity
Exceeding your work capacity listed on your medical certificate after being injured at work can have several negative consequences.
Firstly, it may cause further harm to your injury and delay your recovery. Your medical certificate is issued based on an assessment of your current medical condition and ability to perform work tasks. Exceeding your work capacity could result in additional strain on your injury and worsen your symptoms.
Secondly, it can also affect your insurance claim. Insurance companies may use your medical certificates as evidence of your ability to work and the nature of your injury. If you exceed your work capacity, it may suggest to the insurer that your injury is not as serious as previously indicated and could potentially undermine your claim.
Finally, exceeding your work capacity may also have legal implications. In some cases, it could result in disciplinary action from your employer or even result in the termination of your employment.
To ensure the best possible outcome for your injury and your insurance claim, it is important to follow the guidelines listed on your medical certificate and not exceed your work capacity.
Build Your Team!
Having a team of health professionals support you when making an insurance injury claim can be beneficial for several reasons:
Medical expertise: Health professionals, such as doctors, can provide medical expertise to support your claim. They can help diagnose your injury, provide a prognosis, and assess the extent of your injury-related expenses.
Evidence: Health professionals can provide documentation and evidence to support your claim, such as medical reports, bills, and statements from witnesses.
Representation: Health professionals can represent you and advocate for your rights during the claims process. They can communicate with the insurance company on your behalf and help ensure that your claim is handled fairly.
Understanding of the process: Health professionals are familiar with the claims process and can help guide you through the process.
Stress relief: The process of making an insurance claim can be stressful and emotional. Having a team of health professionals to support you can help reduce your stress and provide emotional support.
Prevent further injury: Accessing treatment early can help prevent an exacerbation of your injury or deterioration in your physical or mental health.
Rehabilitation: Health professionals will assist you to address your injury and provide treatment to assist you to recover and return to work while minimising any long-term impacts of your injury or illness.
In conclusion, having a team of health professionals support you during an insurance injury claim can help ensure that your claim is handled efficiently and fairly. It can also provide peace of mind and help you focus on your recovery while someone else handles the details of the claim.
MAINTAIN AGENCY OR POWER
Who is the Policy Holder?
The policyholder for an insurance claim for an injured worker is typically the employer of the injured worker. In most situations, employers are required to purchase workers' compensation insurance, which covers employees for work-related injuries. The employer is considered the policyholder for this type of insurance, and they are responsible for submitting claims on behalf of injured employees.
The injured worker, the claimant, is considered the beneficiary of the insurance coverage, as they are entitled to receive benefits for their injuries, such as medical expenses and lost wages. However, the policyholder, in this case, the employer, is responsible for managing the claims process and ensuring that the injured worker receives the benefits they are entitled to.
In conclusion, the policyholder for an insurance claim for an injured worker is typically the employer, while the injured worker, the claimant, is the beneficiary of the coverage.
Who Should Hold the Power?
The balance of power in an insurance claim can vary depending on the situation, but generally, it should be held by the policyholder. Policyholders are the ones who have purchased insurance coverage and have a right to expect that their claims will be handled fairly and efficiently.
However, insurance companies are often the ones who hold the majority of the power in the claims process. They have the resources, expertise, and knowledge to process claims and make decisions about coverage and compensation.
To ensure that claimants have a reasonable and fair experience through the insurance claim process, claimants need to be informed about their rights, understand the claims process, and have access to resources and support. Claimants and their representatives should also be proactive in advocating for their rights and seeking the help of professionals, such as advocates, solicitors and lawyers, if necessary.
In conclusion, while the insurer is ultimately accountable to the policyholder, it is up to the claimant to assert their rights and ensure that their claims are handled appropriately and fairly.
The Claimants Responsibilities
Claimants are responsible for taking an active role in ensuring their rights and entitlements when making an insurance claim. They must provide accurate and complete information to the insurance company and other relevant parties, keep detailed records of all communication, medical treatment and expenses related to their injury, and remain informed about the claim process and their rights and obligations.
Claimants should also seek legal and medical advice as necessary, and be aware of any time limits for making a claim. Additionally, claimants should ensure that they are not exceeding the work capacity specified on their medical certificate, and follow any recommended treatment and rehabilitation plans to aid their recovery.
By taking an informed and proactive approach to their claim, claimants can help ensure that their rights and entitlements are protected and that they receive fair compensation for their injuries.
KNOW YOUR RIGHTS
Who Else Can Play a Role in Ensuring the Rights and Entitlements of the Claimant?
In the case of a worker being injured and making a claim under a workers' compensation insurance policy, several parties have a responsibility to ensure the rights and entitlements of the beneficiary, which is the injured worker.
Employer: The employer is responsible for providing a safe work environment and ensuring that workers' compensation insurance is in place. They are also responsible for reporting the injury to the insurance company and cooperating with the claims process. They are also responsible for the return to work process.
Insurance company: The insurance company has a responsibility to handle the claims fairly and efficiently, in a transparent manner, and to provide the benefits that the injured worker is entitled to under the policy.
Government: Government agencies are responsible for regulating workers' compensation insurance and ensuring that insurance companies and employers are complying with their obligations.
Legal Representatives: Legal representatives play a crucial role in ensuring the rights and entitlements of a claimant in the insurance claim process. They are responsible for advising the claimant on their rights and obligations, and ensuring that the claimant is fully informed of the claim process and their options. Legal representatives can also provide support in negotiating with insurance companies, drafting and filing legal documents, and representing the claimant in court if necessary. They have the knowledge and experience to navigate the legal system and advocate for the claimant's rights and entitlements. By working with legal representatives, claimants can feel confident that their rights and entitlements are being protected, and that they are receiving the best possible outcome for their injury and claim.
Treating Health Professionals: Treating health professionals play a critical role in ensuring the rights and entitlements of a claimant in the insurance claim process. They are responsible for assessing and treating the claimant's injury, providing medical documentation and certifications, and advising the claimant on their medical condition and rehabilitation needs. Treating health professionals can also provide expert medical evidence in support of a claim and collaborate with legal representatives to ensure the claimant's rights and entitlements are protected. By working with treating health professionals, claimants can receive the necessary medical treatment, recover from their injury, and have a clear understanding of their medical condition and its impact on their ability to work. This information is crucial in ensuring that the claimant receives fair compensation and appropriate support throughout the claim process.
In conclusion, several parties can assist in ensuring the rights and entitlements of the beneficiary of insurance coverage when a worker is injured. It is important for injured workers to be informed about their rights and to seek help if they feel their rights are not being respected during the claims process.
RETURN TO WORK
Why is Returning to Work Important after a Workplace Injury?
Returning to work after a workplace injury is important for several reasons:
Physical and Mental Health: Returning to work can help individuals physically and mentally recover from their injuries. Work can provide a sense of normalcy and routine, which can aid in the healing process.
Financial Stability: Injuries can result in lost wages and expenses, and returning to work can help to regain financial stability.
Maintaining Skills and Relationships: Returning to work can help individuals to maintain their skills and relationships with co-workers and can prevent feelings of isolation and boredom.
Preventing Further Injury: Staying out of work for a prolonged period can lead to physical and mental deterioration, which can increase the risk of further injury.
Maintaining Employability: Returning to work after an injury can demonstrate to employers that individuals are committed and capable, helping to maintain employability and job security.
In conclusion, returning to work after a workplace injury is crucial for promoting physical and mental health, financial stability, and overall well-being.
Why Early Return to Work is Important?
Studies have shown that the length of time out of work after an injury can have a significant impact on the likelihood of returning to work. Here are a few key findings:
Prolonged Absence: Prolonged absence from work due to injury can increase the likelihood of workers becoming permanently disabled and not returning to work.
Early Return to Work: On the other hand, early return to work, even with modified duties, has been shown to increase the likelihood of a successful return to work. This can help to prevent physical and mental deterioration and maintain work-related skills and relationships.
Timing of Intervention: The timing of intervention is crucial, as the earlier that individuals receive appropriate support, the greater the likelihood of a successful return to work.
Factors that Impact Return to Work: Other factors that can impact the likelihood of returning to work include the type and severity of the injury, the individual's age, job demands, and support from the employer and healthcare providers.
In conclusion, studies have shown that the length of time out of work after an injury can significantly impact the likelihood of returning to work. Early return to work, with appropriate support, is crucial for promoting a successful return to work.
Who is Responsible for Your Return to Work?
The responsibility for an injured worker's return to work typically involves cooperation between the employer, the employee, and healthcare providers.
The employer is responsible for providing suitable job duties and accommodations to facilitate the employee's safe return to work.
The employee is responsible for following their medical treatment plan and working within any restrictions provided by their healthcare provider.
Healthcare providers are responsible for determining the employee's physical capabilities and making recommendations for their return to work. They can also contribute to the rehabilitation plan or where appropriate, or necessary, create a rehabilitation plan specific to their areas of expertise. The latter should be considered in the overall rehabilitation plan.
Ultimately, it is a shared responsibility to ensure the injured worker's successful return to work.
RETURN TO WORK PLAN
What is a Return to Work Plan?
A return to work plan is a document that outlines the steps and arrangements necessary for an injured worker to safely return to their job after an absence due to injury or illness. It may include accommodations, modified job duties, and a timeline for the employee's gradual return to their full job duties.
The plan typically involves input from the employee, the employer, and the healthcare providers to ensure that it is safe, feasible, and meets the needs of all parties involved. The goal of a return-to-work plan is to facilitate the injured worker's prompt and successful return to work while minimising the risk of re-injury.
The return to work plan is usually a collaborative effort between the employer, the employee, and the healthcare provider.
The employer is responsible for providing information about the job duties and accommodations necessary for the employee's safe return to work, while the employee is responsible for sharing their medical information and physical capabilities.
The healthcare provider is responsible for providing information about the employee's medical condition and restrictions, as well as making recommendations for the employee's return to work.
Together, these parties develop a plan that meets the needs of the injured worker and the employer, while ensuring the employee's health and safety.
What is a Psychological Return to Work Plan?
Many people do not realise that a psychologist can create a psychology return to work plan! This is often important as it covers aspects of return to work that might be critical to an injured person's well-being, safety and recovery.
A psychological return-to-work plan is a specific type of return-to-work plan that addresses the return-to-work process for employees who have been absent due to a psychological injury, such as depression, anxiety, or post-traumatic stress disorder (PTSD). It may involve accommodations, modified job duties, and a gradual return to work schedule to support the employee's recovery and successful reintegration into the workplace.
The plan may also include referrals for additional psychological support and resources, as needed. Like all return-to-work plans, the goal of a psychological return-to-work plan is to facilitate the employee's prompt and safe return to work, while minimising the risk of re-injury and promoting long-term recovery.
THE ASSESSMENT PROCESS
Can a Claimant Refuse Psychological Testing Requested by the Insurer?
Yes, a claimant can refuse psychological testing requested by the insurer. Psychological testing can be intrusive and personal, and claimants have the right to control the release of their personal and medical information. I have witnessed clients being subjected to inappropriate and invasive psychological assessments without being fully informed in the process. This is unethical!
However, it is important to understand that the insurer may have a valid reason for requesting testing, and refusing to participate in the testing may impact the claim. The testing may be necessary for the insurance company to fully evaluate the claim and determine the appropriate benefits to be paid.
If you are asked to participate in psychological testing, you may want to ask for clarification on why the testing is necessary and what information will be collected. You can also seek the advice of a lawyer or other professional before deciding to participate in testing.
I would highly recommend finding your own psychologist who is SIRA accredited. The psychologist can usually then apply to have the insurance company pay for your sessions. If your psychologist conducts the psychological assessments, they can ensure it is appropriate for you and your circumstances. The psychologist can also manage the information to minimise its potential misuse by third parties.
In conclusion, while a claimant can refuse psychological testing requested by the insurer, it is important to understand the potential impact of the refusal on the claim and to seek advice from a professional if you have concerns.
Obtaining Your Information?
Many times, I have been told by clients that before they saw me they had testing and they have been denied access to their test results or psychology report. This is unethical!
A claimant can request the results of psychological testing from both the assessing psychologist and the insurer. Claimants have the right to access their medical records, including the results of any psychological testing, and they can request a copy of the results from the assessing psychologist or the insurance company.
In some cases, the insurance company may be required by law to provide the claimant with a copy of the results, although the specific requirements can vary depending on the jurisdiction.
If you are having trouble obtaining the results from the assessing psychologist or the insurance company, you may want to seek the advice of a lawyer or other professional.
In conclusion, a claimant has the right to request and receive the results from psychological testing, and they can seek assistance if they are having trouble obtaining the information.
What is an Independent Medical Examination (IME)?
An independent medical examination (IME) is a medical evaluation conducted by a physician or other healthcare professional who is not the patient's treating physician. It is often used in insurance claims to determine the extent of a claimant's injuries or disabilities and to assess their ability to work. The purpose of an IME is to provide an objective evaluation of the claimant's medical condition and to determine the medical necessity of the treatment or the extent of any disability. IMEs may be requested by insurance companies, employers, or government agencies to help in making decisions related to insurance claims or other benefits.
In New South Wales (NSW), if you have lodged a workers' compensation claim or a motor vehicle accident claim, you may be required to undergo an independent medical examination (IME) as part of the claim process. Under the NSW workers' compensation and motor accident compensation schemes, the insurer has the right to request an IME to obtain an independent assessment of your medical condition and the extent of your injuries.
Refusing to attend an IME may have consequences for your claim. If you do not attend an IME, the insurer may be entitled to suspend or terminate your benefits or deny your claim altogether.
However, if you have concerns about the process, you have the right to request more information about the IME and how it will be conducted. You can also seek legal advice to understand your rights and obligations under the relevant legislation and to ensure that the IME is conducted fairly and impartially.
If you are sent for an IME ensure the assessing doctor or health professional possesses the relevant qualifications to be assessing your condition.
What is an Independent Medical Review (IMR)?
An independent medical review (IMR) is meant to be an unbiased evaluation of a patient's medical treatment or services by a third-party medical expert. It is often used as a way to resolve disputes between patients and their insurance companies regarding medical necessity or the appropriateness of a particular treatment. The goal of an IMR is to provide an impartial assessment of the patient's medical situation to help resolve the dispute.
Can I Refuse an Independent Medical Review (IMR)?
In New South Wales (NSW), the rules regarding the independent medical review (IMR) process depend upon the type of insurance claim being reviewed.
If you have lodged a compensation claim, you may be able to request an IMR if you disagree with the insurer's decision about your claim. You may also be required to undergo an IMR as part of the claims process.
Provided an IMR has been arranged appropriately, you generally cannot refuse an IMR if it is required by the insurer, as failure to attend an IMR can affect your entitlement to benefits. A request for an IMR can be challenged, however, if it has been requested inappropriately.
Any request for an IMR must satisfy certain preconditions. If you are sent for an IMR discuss if this is appropriate with your treating health professionals and legal representatives.
If you have concerns about the IMR process or believe that it has been conducted unfairly, you may be able to seek legal advice or dispute the decision through other means, such as an appeal or review process.
When Should I Obtain Legal Advice When Making a Claim for Injury?
It is advisable to obtain legal advice when making a claim for a work injury if you encounter any of the following situations:
Your claim is denied or not fully covered: If your insurance company denies your claim or only covers a portion of your expenses, you may want to consider seeking legal advice to determine your rights and options.
The insurance company disputes the extent of your injury: If the insurance company disputes the extent of your injury or the cause of the injury, you may want to obtain legal advice to ensure that your rights are protected.
The insurance company requests access to sensitive information: If the insurance company requests access to sensitive information, such as your medical records or psychological evaluations, you may want to obtain legal advice to ensure that your privacy rights are protected.
The insurance company requests an independent medical examination: If the insurance company requests an independent medical examination, you may want to obtain legal advice to understand the implications of the examination and your rights in the process.
The insurance company makes a low settlement offer: If the insurance company makes a low settlement offer, you may want to consider seeking legal advice to determine the fair value of your claim and negotiate a better settlement.
In conclusion, if you encounter any of the above situations or have concerns about your rights and entitlements when making a claim for a work injury, it is advisable to obtain legal advice to ensure that your rights are protected.
When Should I see a Psychologist for a Workplace Injury?
You should consider seeing a SIRA accredited psychologist if you have experienced a workplace injury and you are experiencing any of the following:
Emotional distress: If you are experiencing emotional distress, irritability, forgetfulness, low motivation, anxiety, depression, or trauma symptoms, seeing a psychologist can help you manage these symptoms and cope with the impact of the injury.
Physical symptoms related to emotional distress: If you are experiencing physical symptoms that are related to emotional distress, such as headaches, fatigue, or sleep disturbances, a psychologist can help you identify the underlying emotional issues and develop strategies to manage the symptoms.
Difficulty returning to work: If you are having difficulty returning to work after your injury, a psychologist can help you identify any barriers to returning to work and develop strategies to overcome them.
Difficulty adapting to changes in work capacity: If you have experienced a change in your work capacity as a result of your injury, a psychologist can help you adjust to these changes and develop strategies to manage the impact of the injury on your work and personal life.
In conclusion, if you are experiencing any of the above symptoms or challenges related to your workplace injury, seeing a psychologist can be an important step in your recovery. A psychologist can help you manage the impact of the injury on your mental health and well-being.
How Can a Psychologist Help With a Workplace Injury and Return to Work?
A psychologist can help with a workplace injury and return to work by providing support and guidance in the following ways:
Assessing and managing mental health symptoms: A psychologist can assess and help manage mental health symptoms that are related to the injury, such as anxiety, depression, and post-traumatic stress.
Managing pain: A psychologist can provide support and strategies for managing chronic pain and improving quality of life, which may be especially important if the injury results in chronic pain.
Improving coping skills: A psychologist can help you develop effective coping skills to manage the physical and emotional impact of the injury and improve your overall mental health and well-being.
Addressing barriers to returning to work: A psychologist can help you identify and address any barriers to returning to work, such as physical or emotional limitations, or fears about returning to the workplace.
Developing a return-to-work plan: A psychologist can work with you to develop a return-to-work plan that takes into account your physical and emotional needs. They can also help you communicate your needs to your employer and ensure that a supportive environment is in place to help you successfully return to work.
Assisting with vocational rehabilitation: A psychologist can help you identify alternative career paths, where appropriate, or work arrangements that are compatible with your physical limitations and provide support as you transition to a new role or work setting.
In conclusion, a psychologist can play a crucial role in helping you manage the impact of a workplace injury and successfully return to work by providing support, guidance, and strategies for managing the physical, emotional, and vocational challenges that may arise as a result of the injury.
Find a Psychologist
If you or someone you know is experiencing difficulty, professional support is available. Contact iflow psychology today at 02 6061 1144 to schedule an appointment.
Flexible Counseling Options
iflow psychology offers in-person, telehealth, and telephone counselling services.
As registered psychologists, we provide compassionate support tailored to your needs. Take the first step in your journey towards well-being.
Medicare Rebates and Referrals
With a doctor's referral and Mental Health Plan, you may be eligible for Medicare rebates. Receive quality care while maximising your healthcare benefits. Let us be part of your path to healing.
Complete our simple enquiry form, and our friendly admin team will reach out to you during office hours. We are here to answer any questions and assist you in scheduling an appointment.
Visit iflow psychology in Leichhardt, Inner West Sydney, NSW, Australia for in-person consultations. We also provide convenient telehealth services, ensuring accessibility no matter your location.
The information provided on this website is for informational purposes only. Prior to making any decisions, we recommend consulting your treating doctor, health professionals, and legal representatives. This is particularly important if you have health concerns, existing mental health or medical conditions, or if you feel you are not coping.
(c) 2023 Dean Harrison