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WorkCover Case Managers – Forgetting ethics?

Should WorkCover Insurers’ Case Managers act by a Code of Conduct or a Code of Ethics act as to promote public confidence in WorkCover insurance companies through fair and conscientious dealing. Shoukd they not refrain from any fraud, deceit, misrepresentation, dishonesty, non-disclosure, undue influence or other mischievous practices? Do our Australian WorkCover insurers have a Code of Conduct or a Code of Ethics specifically for their case managers, claim assessors, claims manager etc?

Do you think insurance adjusters hired by the WorkCover Authority (e.g. WorkSafe Vic) to handle injured workers’ claims have and actually read their own code of ethics? Or their own code of conduct?

It would be very hard to believe our workcover insurers have any code of conduct or code of ethics after reading the Victorian Ombudsman’s 2016 report describing what can only be seen as a systemic abuse of claimants.

Claims are routinely denied, with case managers advising injured workers investigations have been completed, when no investigation has been started. Files are closed without any communication, while injured workers wait for answers.

injured Victorian workers are facing a system in crisis, with privacy breaches, lost documents and delayed payments stemming from poor record-keeping by insurance firms, according to the findings in a report by Ombudsman George Brouwer tabled in Parliament on May 2011. The report slammed the performance of Worksafe and the six big insurers it authorises to manage workplace claims.

Ombudsman 2011

It’s also amazing how frequently workcover case managers refuse benefits or payments on the basis the service requested is not considered reasonable and necessary. Of course the reason the service is not considered reasonable and necessary is rarely disclosed, so perhaps case managers also need a remedial course in communication.

Some have even suggested case managers invest in new fax machines and computers and get more organised. It’s amazing how often faxes  and emails appear to get lost and documents misplaced at workcover insurers offices, thereby delaying or even denying claims.

Consider this recent lawsuit by an injured worker against EML Insurance. Where EML  (obviously some case manager or claims assesor) failed to determine the injured worker’s claim within the 2 month period required.In this case, the injured worker took the unusual step of prosecuting her case manager (EML) for its failure to determine her claim for compensation as and when required under the WIMA (NSW).

While the workcover lgislation does provide for ‘penalties’ – e.g. in NSW, a failure to determine a claim in compliance with Part 3 constitutes an offence under s 283 of the WIMA, which is a ‘penalty notice offence’ – we have not heard from other unfortunate injured workers suing their case manager for failing to determine a claim, or even benefits, in a timely manner. Most injured workers just wait while being twisted.

In some shared cases, injured workers did not receive a response to a first request [ for a claim to be determined or a benefit, such as medical treatment to be determined], with their case manager denying receiving the second request! In some cases the case manager ends up sending a letter denying a claim or benefit or request, stating the period had expired! For example, in Victoria you can claim your medical and like services up to a priod of 6 months. Many of us, including myself, have submitted requests for reimbursement for medical appointment fees, and medication costs, only to be told that the submitted ‘invoices’are not on record, or have been ‘misplaced”… and ultimately the 6 month period expires and they just tell you that you are out of date to claim back X or Y!

Note: we know there are some good case managers and not all are of the ‘deny or delay’ school of thought, but clearly this is one industry in need of a course in remedial ethics, conduct and practices!

It appears that we could summarise the Standards of Practice for workcover insurer case managers as follows:

  • The workcover Case Manager must operate only within the context and boundaries of your educational achievements and earned credentials
  • The workcover Case Manager must disclose educational qualifications and professional credentials to clients when required
  • The workcover Case Manager is to maintain knowledge of and practice within laws, regulations and policies implicated in their practice
  • The workcover Case Manager will endeavour to strive for best practice in their work, in line with the National Standards of Practice for Case Management
  • The workcover Case Manager will maintain their professional development in areas of expertise
  • The workcover Case Manager will not provide services where they are aware of a conflict of interest
  • The workcover Case Manager will not accept gratuities, rebates, bonuses, gifts or other remuneration outside of their usual employment arrangements
  • Case Managers must seek guidance from their agency regarding potentially unethical requests or situations
  • The workcover Case Manager must seek guidance from their agency when dealing with any legal concerns
  • The Case Manager must always gain informed consent, including the provision of information for purposes of
    research
  • The workcover Case Manager must advise clients of their rights prior to them agreeing to accept a case management service
  • The workcover Case Manager must fully disclose fees prior to carrying out services
  • The workcover Case Manager will respect peoples right to be an individual and refrain from value judgements
  • The Case Manager will respect a person’s right to self determination and the right to live with risk so long as there is no harm to themselves or others
  • The workcover Case Manager needs to ensure clients are fully informed of services available to them
  • Each individual must operate without discrimination or harassment to others
  • The Case Manager will not be involved in any sexual relations with clients or their carers
  • The Case Manager will consider the best interests of the client as paramount at all times
  • The workcover Case Manager must respect the policy and procedures of their employer

Relevant sources regarding WorkCover case managers and the claims management

We did find the following article on https://www.nursingcenter.com/journalarticle?Article_ID=853076&Journal_ID=54025&Issue_ID=853043

INSIDE CASE MANAGEMENT: Ethical Considerations When Providing Workers’ Compensation Case Management – Professional Case Management
The following document “standards for practice for case management”
The following document applies to Australian Case Managers
The following 2009 document talks about WorkSafe VIC claims management

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Injured workers are not problem people, we are people with a