WorkSafe: complex claims process needs fixing

Victoria’s workers compensation scheme must be recalibrated to ensure that complex claims are resolved in a fair and timely manner, a Victorian Ombudsman investigation has found.

Tabling the Investigation into the management of complex workers compensation claims and WorkSafe oversight today, Victorian Ombudsman Deborah Glass said that while the workers compensation scheme is operating well in the vast majority of cases, the current system fails some particularly vulnerable people.

“The overall system is not broken, but the problems we identified in complex cases – some 20 per cent of the overall claims – go beyond a few isolated examples of bad behaviour. They cannot simply be explained away as a few bad apples spoiling the barrel,” said Ms Glass.

WorkSafe underwrites the Victorian workers compensation scheme with claims management functions outsourced to private insurers. During the investigation period the agent insurers for Worksafe were Allianz, CGU, Gallagher Bassett, Xchanging and QBE. The system currently incorporates a series of financial incentives for agents, including when claims are terminated or workers return to employment.

The investigation examined complex and often extended claims across different industries, roles and injuries (both mental and physical) to assess whether:

• agents unreasonably denied liability or terminated claims
• agents took such actions in order to obtain financial rewards available under the contract with Worksafe
• Worksafe provides effective oversight of the agents and their claims management processes.

Key recommendations from the investigation call for a review of dispute resolution processes within the system and improvements in oversight of complex claims by WorkSafe.

“We found agents cherry-picking evidence to support a decision to reject or terminate a claim – as little as one line in a medical report – while disregarding overwhelming evidence to the contrary. We found Independent Medical Examiners (IMEs) – whose opinions agents use to support their decision making on compensation – receiving selective, incomplete or inaccurate information. We also saw evidence of decisions being influenced by financial incentives to terminate claims.

“In effect, we found cases in which agents were working the system to delay and deny seriously injured workers the financial compensation to which they were entitled – and which they eventually received if they had the support, stamina and means to pursue their cases through the dispute process,” said Ms Glass.

The investigation attracted significant public interest after it was launched, with dozens of workers and others involved in the system contacting the Victorian Ombudsman to offer assistance or make submissions.

The investigation involved detailed reviews of claims across all five agents. A random sample of agent email records was examined and interviews conducted with injured workers and their families, executives from the five agents and former agent staff. Stakeholders including the Accident Compensation Conciliation Service, the Australian Medical Association, the Police Association of Victoria and the Community and Public Sector Union made submissions.

“Action must be taken to address the complex end of the system where terminations are rewarded. WorkSafe needs to examine its incentives – and the use of IMEs – to ensure the system rewards sustainable decisions and to target its oversight accordingly. The process for resolving disputes also demands careful reconsideration – it is in the interests of workers, employers and the public at large that the resolution of claims should be both timely and fair.

“WorkSafe has begun addressing many of these issues, and we have already seen improvements since my investigation began in 2015, but this work must go on. The cases we investigated are not merely files, numbers or claims; they involved people’s lives, and the human cost should never be forgotten,” said Ms Glass.

Report: Investigation into the management of complex workers compensation claims and WorkSafe oversight

Notes to editors

• The Victorian workers compensation scheme is funded by a compulsory system of insurance that covers employers for the cost of providing compensation to injured workers.
• Worksafe manages around 90,000 workers compensation claims a year.
• The Victorian Ombudsman investigation conducted a detailed review of 65 complex workers compensation claims; most claims involved decisions made in 2014 – 2015.
• Insurers acting as Worksafe agents at the time of the investigation were: Allianz, CGU, Gallagher Basset, QBE and Xchanging. The Victorian Government decided in April 2016 not to renew QBE’s contract and QBE ceased acting as a Worksafe agent on June 30 2016. EML replaced QBE on the panel of agents. EML decisions and actions have not been examined during this investigation.

Media contact: Mob 0409 936 235 | vomedia@ombudsman.vic.gov.au