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WIRO Solutions Brief Issue 27 | Case Studies

Each month, the Solutions Group deals with hundreds of complaints and enquiries from injured workers about their workers compensation insurers. The following case studies are real examples of outcomes that have been achieved during the months of May and June 2019 because of our intervention. Names and other details have been edited to protect the privacy of individuals. 

Delay in Reimbursement of Medical Expenses

A worker contacted WIRO as she believed she was entitled to a reimbursement of "around $70" for medications she'd paid for. Following our preliminary inquiry, the insurer undertook an audit of outstanding reimbursements and found that she was owed closer to $2,000.00. The funds were transferred within two days.

Icare Imposes its own Fees in Place of SIRA Fees Order

A claim was made for hearing aids. The insurer accepted the claim in December 2018, and advised the provider of same with reference to ‘gazette rates 2018’. The hearing aids were fitted, and a tax invoice was sent to the insurer in the amount of around $6,600.00. The insurer only paid $5,500.00 and claimed the 2018 fees order only allowed for hearing aids to be covered up to $1,700 per aid, excluding accessories. The insurer advised WIRO that the provider had fitted ‘more expensive’ hearing aids and reiterated that the capped fee per hearing aid is $1,750. WIRO requested clarification of the insurer’s assertions specifically regarding the clause in the Fees Order. In response, the insurer sent WIRO a copy of the Icare Hearing Device Schedule, which is an internal document that lists types of hearing aids and a series of prices. A Further Inquiry was issued noting that an Icare document for internal commercial purposes does not override s 60(2C)(c) WCA, only the SIRA Fees Order sets the maximum fees and the claim complies with that order. The insurer did not address this in its response, but confirmed that it would pay the original invoice in full. 

Premature Cessation of Entitlement to Medical Treatment

An insurer sent the worker a letter advising of the pending cessation of her medical entitlements. The worker telephoned WIRO. During the phone conversation, WIRO ascertained that there may have been some injury-related loss of income in 2018 that the insurer had failed to note. We received a pay slip that confirmed the payment of make-up for one week in 2018. WIRO presented this information to the insurer as it appeared that the employer had paid this without advising the insurer. WIRO suggested the insurer investigate this payment and re-examine the period for which the worker would be entitled to claim medical treatment expenses.  

Annual Leave Included as Payments

The worker complained to WIRO that his weekly benefits were paid incorrectly during a closed period. WIRO followed up with the insurer and requested a list of payments. WIRO noted that the insurer had mistakenly included annual leave and sick leave in its calculations as “earnings”. The insurer agreed that it had erred and made an adjustment payment of approx. $10,000 to the worker. 

Underpaid Weekly Payments 

The worker’s lawyer served a claim for weekly benefits in March 2019. The insurer requested particulars that day, which the lawyer provided two weeks later. In April 2019, the insurer advised that it was unable to determine the claim because the particulars were inadequate and it cited a provision that applies to claims for lump sum compensation and work injury damages but not weekly benefits. Following WIRO’s complaint, the insurer advised that weekly benefits would be processed for the outstanding periods shortly after consultation with the employer. Four weeks later, the lawyer contacted WIRO again to confirm that no further benefits had been paid. WIRO sent a further email to the insurer, which replied that following a thorough review all outstanding discrepancies had been rectified. It stated that there was a lot of confusion with the employer about what to pay as the worker had been claiming annual leave and sick leave as well as performing suitable duties in some weeks. The case manager then reconciled the wages paid from the insurer to the employer and the payments made by the employer.  It was agreed that the worker was underpaid $11,000.00. The shortfall was paid within 24 hours.

Delay with Weekly Benefits

A worker alleged that since his date of injury, weekly payments had differed from week to week and he had been unable to resolve this matter with his case manager. As he had no capacity to work since the DOI, the payment amount should be the same each week (95% of PIAWE). The insurer told WIRO that it believed all payments had been completed, but there may have been a discrepancy with the tax component. The employer was not prepared to provide copies of pay slips and so the worker sent his records of payments to the insurer to assist. The insurer continued to have difficulties with the employer. After several unsuccessful follow-ups, WIRO issued a Further Inquiry. While the insurer was preparing its response, WIRO learned that the worker was now homeless, due in part to the delay in receiving weekly payments. The insurer stated that it was still experiencing difficulties with the employer, but agreed to accept the worker’s evidence and a deposit was processed that day. The insurer also arranged for the worker to get in touch with community support services. 

Change of Venue for Independent Medical Examination 

The worker complained that the insurer had arranged an IME appointment in suburban Sydney despite a specialist being located closer to her home on the Central Coast. WIRO contacted the insurer noting that the claim related to a psychological injury and that this injury may make travel difficult. The insurer agreed to change the venue for the IME. 

Weekly Benefits for a Worker with Highest Needs 

The worker’s wife contacted WIRO to discuss her husband’s claim. Through targeted questioning, it was confirmed that the worker had been assessed at 52% WPI and a Certificate of Determination was issued to that effect earlier this year. WIRO identified that the worker was not receiving the minimum weekly entitlement pursuant to Section 38A WCA. Upon contacting the insurer, we were advised that the entitlement was not increased due to an oversight and a back payment of more than $2,000.00 was made.

Delay in Determining Liability for a Claim

An insurer issued a reasonable excuse notice to the worker in March 2019, on the basis that the injury was not reported within two months, and stated that a liability decision would be made by an appointed date in April. Five weeks after that date, no decision had been made and the worker complained to WIRO. WIRO contacted the insurer. While the insurer did not explain the reason for the delay, it accepted liability and paid nearly $8,000.00 in outstanding benefits to the worker.

Dispute about Medical Treatment Citing Section 59A WCA

The worker’s claim for left shoulder surgery was disputed. The insurer asserted that the worker’s entitlements had ceased pursuant to Section 59A WCA because the degree of permanent impairment had not been determined and more than two years had passed since weekly payments were last paid. WIRO referred the insurer to s 59A(3) WCA and the decision in Flying Solo Properties Pty Limited t/as Artee Signs v Collet [2015] NSWWCC PD 14, where the Deputy President stated that the insurer should pay for the surgery because as soon as the worker undergoes the surgery he would have no current work capacity. The insurer stated that it was not aware of that decision and that its decision to dispute surgery was based on legal advice from its lawyers in a similar matter. The insurer then accepted the claim.

Delay in Payment of Certificate of Determination

A Certificate of Determination was issued in March 2019, but although nearly three months had passed no payments had been made to the worker. The self-insurer continued to blame Centrelink for delaying the payment. Following contact from WIRO, the self-insurer claimed that it had suffered a security risk 2 weeks previously and had to shut down all IT systems until the threat could be rectified. Although the insurer said the system was now online, there was a back log of payments and interest would be applied if the payment was not made in time. WIRO contacted the insurer regularly over the next few weeks seeking an estimated date for payment. A few days later the insurer claimed to have suffered another security breach, which would further delay payment. The worker and his lawyer both contacted WIRO claiming that the worker was in financial distress as his Centrelink payments had ceased. The next week, WIRO was contacted by the office of the worker’s local MP, who had taken an interest in the case. WIRO phoned the insurer and made it aware of the MP’s involvement. The insurer asked for 30 minutes to review the matter and then advised that the payment would be released. The worker was back-paid nearly $40,000.00.  

Errors in PIAWE Calculation 

The worker worked two jobs and wanted to know why wages from his second employer could not be included in his PIAWE. He had suffered a significant injury to the jaw and PTSD and said that his financial situation was causing him further distress. WIRO advised the worker that due to the legislation, it was rare for secondary employment be included in PIAWE. Nevertheless, we raised a preliminary inquiry. While the secondary employment could not be considered in the calculation of PIAWE, the insurer’s response demonstrated that PIAWE for the worker’s primary employment had not been calculated correctly.  The insurer said that PIAWE had been calculated pursuant to Schedule 3, Item 2 WCA. However, as the worker was employed as a casual, Item 2 should not have been applied. The calculation also included weeks in the relevant period when the worker did not work. WIRO raised these issues with the insurer, but its initial response failed to address the issues raised.  WIRO escalated the matter to a technical specialist and suggested that Item 6 ought to apply for 40 hours per week, rather than 32 fixed hours initially assessed by the insurer. The insurer agreed and it increased the rate of PIAWE by more than $300.00. 

PIAWE for Worker Injured as an Apprentice

The worker was injured in 1987 while he was an apprentice. He recently made a claim for replacement dental work, which was accepted. He would be required to take approximately 5 weeks off work following the procedure and the insurer advised him that he would be paid $302 per week (indexed amount). WIRO contacted the insurer and referred it to Item 1 of Schedule 3 WCA, which provides for the increase in PIAWE to a figure that the worker would have been earning as he progressed through an apprenticeship into a qualified trade role. The insurer agreed to adjust the rate of payment before the worker took time off work. 

Delay in Determining Claim for Surgery 

The worker alleged that he had submitted a request for disc removal surgery in May 2019, but had not received a response after more than three weeks. WIRO contacted the insurer, which admitted receiving the claim and said it was awaiting clinical notes from a hospital. The hospital advised that it would take 28 days to get the notes and the insurer said it would determine the claim then. WIRO pointed out the legislative timeframes set out in s 279 WIMA, which had already expired and the insurer approved the surgery.

Calculating PIAWE for a Working Director

The worker complained that the insurer was refusing to include earnings from her secondary employment as part of her PIAWE, which it calculated as $200.00. The insurer advised that it would not include earnings from the worker’s own business as the worker was a sole trader. WIRO was supplied with an ASIC company registration to demonstrate that the worker was not a sole trader. This which was forwarded to the insurer. The insurer rejected this evidence and preferred its own questionnaire, which asked “Do you carry on an independent business in your own name or under a business or firm name?” to decide that she was a sole trader. WIRO raised a Further Inquiry and requested the insurer to review the evidence from ASIC that the worker is the managing director of a registered company and to review the PIAWE calculation. WIRO later referred the matter to Icare, which agreed that the worker was a managing director and that those earnings should be included in PIAWE. As a result, PIAWE was increased by more than $1,000.00 and the worker was back paid more than $16,000.00.

Delay in Determining Liability for Surgery 

The worker submitted a claim form in March 2019. In response, the insurer asked him to attend an IME in May 2019. The worker contacted WIRO for assistance in June 2019, alleging that calls to the case manager went unanswered and the claim had not been determined. The insurer told WIRO that it had received the IME report, which was not supportive. It had sent a copy of the report to the NTD and that a liability decision would not be communicated until the NTD provided a further opinion. WIRO raised a Further Inquiry noting that the insurer had already exceeded the statutory timeframes for determining the claim and requested the insurer to provide a formal response without further delay. The insurer then provided WIRO with a copy of the dispute notice and the worker was referred to a lawyer for assistance. 

Weekly Benefits Retained by Employer

The worker’s lawyer complained to WIRO that the worker’s weekly payments for a closed period were being withheld and that he did not receive any payments from his employer at the commencement of the provisional liability period. He became job detached soon afterwards and the insurer commenced ongoing direct payments. The insurer provided WIRO with a summary of payments made and stated that, “the employer continued paying the worker immediately from notification of injury despite not getting payments from us due to an issue with cheques not being received. Worker was never without during these periods”. However, the worker continued to assert that no payments were made by the employer and WIRO asked the insurer to obtain payslips for the specified period to verify that the payments had been made. It was then revealed that the employer had not passed on any monies to the worker and an email from the employer indicated that no payments were made because its payroll department was advised not to make any payments. The insurer acknowledged the error and made an immediate back-payment directly to the worker.

PIAWE not Indexed Properly 

The worker complained that his payments had not been indexed throughout his claim. In response to WIRO’s Preliminary Inquiry, the insurer said that the employer had not given a pay rise since the date of injury and that indexation would not be applied. It said that ordinary earnings were around $1,250.00 per week and the worker was receiving 80% of this (around $980.00). However, WIRO noted that 80% x $1,250.00 was $1,000.00. The insurer then stated that the worker’s ordinary earnings had been recalculated in September 2017 and determined as $1,200.00. The worker insisted that his ordinary were $1,250.00. WIRO raised this issue with the insurer, which confirmed that the worker had received a pay rise during the relevant period and that PIAWE was calculated as the at average of both pay rates. WIRO again asked why indexation had not been applied and the insurer continued to assert that the employer had not given him a pay rise. WIRO referred the insurer to s 82A WCA, which applied as PIAWE was less than the amount he would have been earning had he remained in employment. The matter was escalated within the insurer, which then agreed that indexation should have applied. The worker was back-paid more than $4,000.    

Payment for Person to Escort Worker to IME

The worker, who lives in northern NSW, was asked to attend an IME in Sydney. Due to the nature of her injuries she required an escort to accompany her to the appointment. The worker asked the insurer on several occasions if it would cover the travel expenses of the escort, but did not receive a response. Following WIRO’s involvement, the insurer confirmed it would cover the escort’s costs. 

Section 59A and a Claim for Artificial Aids

The worker’s claim for a total knee replacement was disputed under s 59A WCA. The insurer asserted that the entitlement period was five years after weekly payments were last paid and that s 59A applied from 31 December 2017. WIRO queried the insurer’s position on two grounds: (1) The worker had received compensation for 35% WPI, which entitled them to medical treatment for life; and (2) the claim for a total knee replacement would be considered “an artificial aid” and is therefore exempt from the limiting provisions of s 59A. The insurer agreed to review the claim on the basis that the s 59A limitation did not apply.