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WIRO SOLUTIONS GROUP OPERATIONS AND TRENDS

KATHRYN MITCHELL MANAGER, SOLUTIONS GROUP

SYDNEY, 6 APRIL 2017

WORKERS COMPENSATION INDEPENDENT REVIEW OFFICE - (WIRO)

Relevant functions set out in s27 and s27A of Workplace Injury Management and Workers Compensation Act 1998.

27 Functions of Independent Review Officer

(a) to deal with complaints made to the Independent Review Officer under this Division

27A Complaints about insurers

(1) A worker may complain to the Independent Review Officer about any act or omission (including any decision or failure to decide) of an insurer that affects the entitlements, rights or obligations of the worker under the Workers Compensation Acts.

(2) The Independent Review Officer deals with a complaint by investigating the complaint and reporting to the worker and the insurer on the findings of the investigation

(3) The Independent Review Officer is to deal with a complaint within a period of 30 days

Enquiry and Complaint Handling Protocol

• WIRO is the agency with the statutory obligation to handle complaints by workers about decisions of insurers regarding workers compensation claims.

Workers Compensation Independent Review Office 2

A CHANGE IN APPROACH TO COMPLAINTS


• Agreement with insurers to respond to preliminary enquiries (requests for information) within 2

business days

• Follow up requests for information should also be responded to within 2 business days

• Solutions driven

• Win-Win outcomes

• Do not provide legal advice

COMPLAINT AND ENQUIRIES


• 1 July 2013 to 24 March 2017 – 55,560 calls though 13 WIRO

• Average of 1,213 Calls per month

• 1 October 2012 to 24 March 19,319 Complaints and Enquiries

• Average of 324 Complaints/Enquiries per month this year

COMPLAINT AND ENQUIRIES 2015/2016 BY INSURER


1 July 2015 to 30 June 2016

COMPLAINTS ENQUIRIES

Scheme Agent 71% 64%

Self Insurer 10% 6%

Specialised Insurer 4% 3%

TMF 15% 11%

Not Provided – Enquiry/hearing loss

0% 16%

COMPLAINT AND ENQUIRIES 2017


COMPLAINT ISSUE PERCENTAGE

1 Medical Treatment 13.50%

2 Denial of Liability 13%

3 Rehabilitation/RTW 12%

4 Delay in Determination of Liability 11%

5 Weekly Benefits 9%

6 s39 9%

7 Communication 8%

8 IME/WPI 8%

9 PIAWE 6.50%

10 Work Capacity (General) 6%

11 Delay in payment COD 4%

SCHEME AGENT COMPLAINTS 2016


Scheme Agent

Expected Breakdown of Complaints Based on

Market Share

Breakdown of Complaints

Received by WIRO

Variation from Estimated Market Share

Allianz 618 651 +5%

CGU 381 415 +9%

EML 306 438 +43%

GIO 780 373 -52%

QBE 306 514 +68%

1. MEDICAL TREATMENT


• The worker required further treatment and contacted her insurer who informed her that her claim was closed.

• The insurer had not received any requests for treatment and as the worker had elected not to participate in a Return to Work program the Rehabilitation Provider closed their file. The insurer hadn’t received a certificate of capacity since August.

• Moreover, the worker had been out of the country for a few months and a finalisation letter had been sent to the worker on 01/12/2016.

• Upon contact from WIRO the insurer agreed to review any referrals for treatment as the worker still had an entitlement under s59A.

• The worker subsequently sent in referrals for an ultrasound and cortisone injections and they were approved on 21/12/2016.

2. DENIAL OF LIABILITY


• The worker’s rehabilitation provider complained to WIRO that further rehab hadn’t been approved following the issuing of a s74 Notice declining all ongoing liability for the injury.

• The worker was very keen to return to the workforce following a psychological injury at work, but needed return to work assistance.

• Upon intervention by WIRO alerting the insurer to s41A of the WIM Act the insurer agreed to approve further rehab services for an amount not exceeding $6,200, as per the plan submitted by the rehab provider.

41 Object and application of Chapter

• (1) The object of this Chapter is to establish a system that seeks to achieve optimum results in terms of the timely, safe and durable return to work for workers following workplace injuries.

41A Chapter applies even when liability disputed

3. REHABILITATION


• The injured worker’s employer changed her rostered days from Tuesday, Wednesday and Thursday to Monday, Wednesday and Friday as they believed she needed a day off in-between each shift to assist with recovery.

• The worker said this is not based on any medical advice. • The worker said her childcare arrangements are based around the originally rostered shifts and it will be

extremely difficult to rearrange childcare to align with the new roster, specifically Monday and Friday. • WIRO pointed out that the Guidelines for return to work programs state: In developing return to work plans, consideration should be given to: • The personal circumstances of injured workers that may impact suitable duties, for example, child care

arrangements. • The insurer was not aware that the worker’s roster had changed and upon notification they made contact

with the employer to discuss the change. • The employer subsequently made contact with the worker to advice of the roster change back to the

original hours/days.

4. DELAY IN DETERMINATION OF LIABILITY


• The worker’s solicitor contacted WIRO due to a long delay in determining liability for surgery. • The worker suffered an injury to her lumbar spine in a fall at work on 17 February 2000. • The insurer funded her lumbar spine surgery in October 2012 and September 2013. • 5 May 2016 her treating neurosurgeon sought approval to perform a spinal fusion and disk

removal. • 22 August her NTS provided a medical report upon request by the insurer. • 23 November she attended an IME arranged by the insurer. He didn’t recommend the

surgery. • 20 March 2017 the insurer requested that the NTS confirm he had read the IME’s report and

to advise whether he still recommends the surgery. • Surgery was declined on 28 March in response to WIRO’s Preliminary Inquiry.

5. WEEKLY BENEFITS


• The worker provided her insurer with a certificate of capacity downgrading her from 15 hours per week to no capacity.

• The downgrade relates to the use of a new medication (Duloxetine) used to relieve nerve pain.

• The insurer ceased her weekly payments on the basis that they need further information from the NTD in relation to the downgrade.

• WIRO raised a Preliminary Inquiry referencing s54 of the 1987 Act, which details that a notice period is required when weekly payments are discontinued or reduced by the insurer.

• WIRO noted that the worker should continue to receive the current rate of payment whilst the downgrade from 15 hours per week to nil capacity is investigated.

• Liability for the downgrade was accepted and the employer paid the worker for the unfit period.

6. SECTION 39


• An injured worker contacted WIRO as she had been asked to attend an IME in Sydney to ascertain her WPI to see if she was entitled to weekly benefits beyond 260 weeks.

• She lives in Broken Hill and had previously had spinal fusion surgery in Adelaide in 2010 fusing 11 vertebrae. She said she would prefer not to travel to Sydney given the extent of her injuries.

• She complained that her case manager doesn’t return her calls and said, “She is often in a meeting or unavailable.”

• Lump sum compensation paid in 2008 only. • I referred her to get legal advice and Kim Garling referred this case to icare for

review. • Her DOI is 17/08/1995 and she was told by her surgeon no further surgeries could

assist her. She is 55.

7. COMMUNICATION


• A worker contacted WIRO on advice from her lawyer on 7/11/16. • In 2015 the worker’s claim had been declined. • Following an Internal Review in September 2016 the decision was overturned but

her weekly benefits had not been reinstated. She was receiving Centrelink benefits. • For 2 months her lawyer had been attempting to contact the insurer with no

response. • The insurer had requested a clearance from Centrelink on the 05/10/16 but

unfortunately the incorrect dates were entered so a second request was sent to Centrelink, received on the 31/10/16.

• The insurer did not have a certificate to enable payment for the 2 month period. WIRO obtained the certificates from the IW and a payment was made that afternoon for four weeks of benefits.

8. IME


• The worker lives in northern NSW. • An IME had been arranged 1.5 hours from her place of residence. • The worker was unable to attend the IME for 3 reasons – the time of the appointment did

not allow for the worker to arrive home in time to pick up one child from school; the travel to the appointment was along a winding road and given her shoulder injury she was concerned of doing further damage; and lastly she did not have care for her second child with special needs and would need to take him with her.

• WIRO discussed alternate travel locations with the worker who confirmed South Coast QLD would be a better option if available.

• The insurer agreed to change the IME appointment and provided the worker with 3 alternative IME options, all located on the QLD border.

• The worker was then able to choose a day on which both of her children had alternate care arrangements.

9. PIAWE


• The worker has a WPI of 28% WPI. His DOI is 28/03/1995 and he has been working since DOI but may be medically retired shortly. He works for a Regional Council supervising work on the gardens.

• He was not in receipt of weekly benefits immediately prior to 01/10/2012 and as a non-existing recipient of weekly benefits his PIAWE will be calculated based on his earnings back in 1995.

• His employer advised that his base rate of pay per week prior to injury was $466.70.

• This PIAWE was indexed from the 01/04/2013 to date and currently sits at $513.00.

• He was very concerned about his benefits being reduced so drastically. • WIRO confirmed the insurer is applying the law correctly.

10. WORK CAPACITY


• The worker said her weekly payments were terminated as of 17 December 2016. • She alleged that she did not receive notification in writing until her case manager recently

forwarded her a letter dated 2 September 2016. • The letter stated that the insurer considered the worker hadn’t met the requirements of s38,

Special requirements for continuation of weekly payments after second entitlement period (after week 130)

• In addition, it is noted that the insurer continues to rely on the work capacity decision review by the Merit Review Service from June 2014.

• The worker alleged that the Merit Review Service found her to have no work capacity and an ongoing entitlement to weekly payments.

• She alleged that she submitted certificates of capacity to the insurer which certify her with nil capacity for work. WIRO pointed out that, on this basis, the worker’s payments should continue past 130 weeks in accordance with s38(2).

• The insurer conceded that an error had been made. They noted that they have since contacted the worker to tell her to disregard the letter and that weekly payments will continue.

11. DELAY IN PAYMENT OF COD


• The worker was awarded 3 months of weekly payments in the WCC in September 2016; however he had not received any reimbursement from his employer.

• The insurer advised a wage reimbursement payment was made to the employer on 27/10/16 (following receipt of a Centrelink clearance) via cheque. This was banked by the employer on 8/11/16.

• The insurer only became aware that this payment had not been passed on by the employer at the time of WIRO’s enquiry on 2/03/17.

• WIRO suggested the insurer reimburse the worker and seek recovery from the employer.

• However, the employer then paid a total of $ 5,458 directly to the worker.

CONTACT US


wiro.nsw.gov.au or 13 9476

Subscribe to our WIRO Bulletin:

[email protected]

http://www.wiro.nsw.gov.au/

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