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Resolving Disagreements and Disputes
> Obligations
> Disagreements about injury management
> Disputed workers compensation claims
> Templates & References
Obligations
WorkCover requires that all employers have a predetermined approach to disagreement and dispute resolution. Use the following notes to improve this section of your RTW Program.
Disagreements about injury management
> Disagreements about money
> Disagreements about suitable duties
> Disagreements about treatment
> Disagreements about plans
> Disagreements about accredited rehabilitation providers
Disagreements about money
Ensure that your RTW Program includes procedures for paying workers their entitlements:
- Permit your workers to access their sick leave as per award arrangements and if they provide a medical certificate. If the medical condition is subsequently accepted as a compensable injury, credit the sick leave to the worker. The organisation will be reimbursed by the insurer for sick leave already paid during the period that weekly compensation was payable to the worker.
- Ensure that your organisation passes on to the worker all monies that the worker is entitled to under the workers compensation legislation. Note that it is an offence to refuse or to delay passing on monies and the fine is a maximum of $55,000.
- Include as essential documentation an expenses sheet that the RTW coordinator gives the injured worker at the first interview. The worker will be able to easily track any out of pocket expenses, for example, travel, chemist accounts that can then be reimbursed.
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Disagreements about suitable duties
Disagreements usually occur when the injured worker refuses the duties, your organisation refuses to offer them, or the injured worker does not progress through the duties provided.
In all these cases, either you or your insurer may engage the services of an injury management consultant. These are medical practitioners approved by WorkCover specifically for the purpose of reviewing a worker's fitness for suitable employment and the availability of suitable employment at the workplace. If required, they will visit the workplace, examine the worker and communicate with the nominated treating doctor to arrange an agreed return to work.
The usual procedure for referral to an injury management consultant is via the insurer.
Disagreements about treatment
You can refer disagreements about the treatment being provided, including the need for ongoing treatment, for a second opinion. Use your company doctor or an injury management consultant to give the worker a second opinion and to communicate this to the nominated treating doctor.
If the treatment is physiotherapy or chiropractic then contact your insurer to refer to one of the WorkCover NSW approved independent physiotherapist or chiropractic consultants. They “peer review” the appropriateness of the treatment provided.
Disagreements about plans
The context of injury management is one of teamwork or "mutual obligation". This means that both workers and employers must cooperate with any plans that have been developed. Remember that both you and the worker would have been involved in developing and agreeing to these plans so the content of the plans should be no surprise.
There are penalties for employers who do not cooperate with injury management - up to a $5,000 fine. Workers who unreasonably refuse to co-operate with their injury management plan and their employer's RTW plan, may find their weekly benefits reduced or stopped by the insurance company.
Disagreements about accredited rehabilitation providers
Injured workers have the right to choose the accredited rehabilitation provider allocated to their case. There will be fewer disagreements about choice of provider if the initial selection of providers listed in your RTW Program was done in consultation with workers. Complaints about the services of accredited providers should be discussed directly with the provider and if not resolved the matter may be referred to WorkCover's Injury Management Branch.
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Ensure your RTW coordinator is trained in negotiation skills and conflict resolution. |
Accreditation requires all organisations to have complaints procedures and disciplinary/grievance processes. Use these procedures in the development of your RTW program. Ensure the DON and RTW coordinator are trained in conflict resolution. |
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Disputed workers compensation claims
> Notification
> Claims Assistance Service
> Workers Compensation Commission
> Disputes about permanent injuries
Notification
Disputes about workers compensation claims are more formal. They require the worker to be notified in writing by the insurer that the claim is in dispute, and why, and often requires the worker to make an application to challenge the insurance company.
If the insurer disputes the liability of the claim they must:
- advise the worker of this in writing;
- provide reason(s) for the dispute;
- advise the worker to seek advice or assistance from his/her union or legal representative; and
- provide contact details for the Workers Compensation Commission.
You will receive a similar letter from the insurer notifying you the claim is in dispute.
The NSW dispute resolution system has 2 new structures - the Claims Assistance Service and the Workers Compensation Commission.
Claims Assistance Service
Part of the wider WorkCover Assistance Service, this client contact centre provides assistance to injured workers and employers with questions about workers compensation and injury management. It provides information about making a claim, the dispute resolution process, entitlements, and accident notifications.
The aim of the service is to resolve grievances and misunderstandings through discussion and education and so prevent a grievance from turning into a dispute that is lodged with the Workers Compensation Commission.
The staff of the Claims Assistance Service will actively become involved in tracking a particular claim, communicating with you, your insurer, and the worker, in an attempt to resolve the problem. The Service will also assist to resolve situations where you disagree with the insurer's handling of a worker's compensation claim, and cannot resolve the dispute by discussion.
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Workers Compensation Commission
The Workers Compensation Commission handles disputes about workers compensation claims involving:
- weekly payments of compensation,
- workplace injury management,
- medical and related expenses,
- permanent impairment/pain and suffering,
- death of the worker,
- property damage.
The aim of the Commission is to attempt conciliation in the first instance. All parties to the dispute have the right to legal representation.
Any party to a dispute can make an application about weekly benefits, medical and related expenses, payment for damages to personal property and/or management of the worker's injury in the workplace. Only a worker, or his or her representative, can make an application about permanent impairment and/or pain and suffering.
Application forms and an explanation of the application process are available via the Workers Compensation Commission at Level 21, 1 Oxford Street, Darlinghurst Tel: (02) 9243 8800 or 1300 368 040 or their website.
Disputes about permanent injuries
Specialist doctors contracted by the Workers Compensation Commission resolve disputes about permanent impairment and other medical disputes. These doctors are called approved medical specialists.
The approved medical specialist may consult with any treating practitioner, call for medical records and/or examine the worker. They must use WorkCover's permanent impairment assessment guidelines - WorkCover Guides for the Evaluation of Permanent Impairment. They measure permanent impairment for the various body parts and systems, and consider this impairment in relation to the 'whole person'.
After investigating the medical dispute the approved medical specialist will issue a Medical Assessment Certificate. This is the final, binding opinion in disputes about permanent impairment.
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