The Victorian workers compensation scheme (WorkCover) can be challenging to navigate for many injured workers. It takes a village to help an injured person recover physically and mentally after a traumatic accident. This “village” mainly comprises of doctors, insurers, lawyers, employers and the wider community. In my experience, I find that when these parties are not working cooperatively, it can significantly hinder the worker’s road to recovery. In this article, we provide a guide for General Practitioners about the claims process and answer some of the common questions raised by GP’s.
As a GP, you are usually the injured worker’s first point of contact following an accident. Your medical guidance and support are the foundation of an injured worker’s recovery and journey through the workers compensation scheme. You will be a part of this worker’s journey and will be asked to comment on their injuries for however long it takes them to recover.
The current Victorian workers compensation scheme has been around since the 80’s. The scheme can be difficult to navigate and difficult to remember all the rules and procedures involved. This often adds a further psychological burden on workers with physical injuries as they become stressed and frustrated with the system. A GP who understands that system will play a critical role in the worker’s overall recovery.
Our WorkCover guide for treating doctors
A patient comes to me with a work injury. What do I need to be aware of regarding the WorkCover claim?
The first step is to make sure you are correctly and accurately recording the worker’s description of what happened and the date of injury. Ideally this should not be your interpretation but an actual account of what they told you. Often that initial note will be taken to be evidence of what the worker said happened.
You should let the worker know that they may be able to make a claim for workers compensation. Rather than spending your time giving them any advice about the claim process and evidence required to support a claim, you should recommend they speak with a lawyer practising in Victorian workers compensation law. Often by involving a lawyer in the process early, a number of disputes with the insurer can be avoided.
What are common entitlements that workers can claim?
A worker has four main entitlements under the Victorian workers compensation scheme governed by the Workplace Injury Rehabilitation and Compensation Act 2013 (Vic):
- Weekly payments
- Medical expenses
- Impairment benefit claim (lump sum payment)
- Common law (damages) claim
1. Weekly payments
A worker is entitled to weekly payments depending on their work capacity.
If they do not have a current work capacity (that is, they cannot currently work due to their injuries), a worker is entitled to up to 130 weeks of payments.
If they do have a current work capacity but only to work reduced hours, they may be entitled to the difference in earnings.
A worker requires a valid Certificate of Capacity signed by their treating doctor to access this entitlement. Without a valid Certificate of Capacity, they cannot receive payment. The first certificate must be signed by a GP. Any subsequent certificates can be signed by an allied health provider.
2. Medical expenses
A worker is entitled to reasonable costs of medical and like services to manage their injury. “Like” services refers to assistance beyond medical; for example, home help or gardening help.
WorkSafe Victoria has a fee schedule confirming the reimbursement rates they would pay for medical services. If you charge outside this fee schedule, the injured worker will likely have to pay out of their own pocket. Visit the WorkSafe Victoria website to download a copy of the most recent reimbursement rates.
Any medical or like services that a worker is claiming must be supported by their treating doctor. GP’s are frequently asked by the WorkCover insurers to provide clinical justification for a particular treatment or service. Without this justification and support, the worker may not be able to access the treatment or service sought.
3. Impairment benefit claim – lump sum compensation (after 12 months from the date of injury)
An impairment benefit claim is a claim for lump sum compensation for permanent injuries.
The level of impairment caused by the injury is assessed based on the American Medical Association Guidelines 4th edition (AMA guides) and given a percentage. For a worker to be entitled to compensation, they must rate at 5% or more for Musculo-skeletal injuries, 10% or more for non-Musculo-skeletal injuries and 30% or more for psychological injuries.
When a claim is lodged, the worker may be required to attend an independent medical examination with a doctor that holds certification in AMA guides assessment.
4. Common law claim for damages (after 18 months from the date of injury)
A common law (damages) claim is a claim for lump sum compensation for pain and suffering and economic loss caused by the injury. For a worker to be entitled to damages, they must establish that they have a serious injury and that the employer, or a third party breached their duty of care and caused the injury (negligence).
In general terms, a serious injury refers to the consequences of the injury on the worker’s quality and enjoyment of life and ability to earn an income. Negligence refers to circumstances where the employer or a third party had failed to take precautionary steps to prevent the injury from happening.
Can I give a generic medical certificate?
A generic medical certificate is not sufficient to allow an injured worker to access weekly payments. You must complete and sign on the prescribed Certificate of Capacity.
The injured worker will also be required to sign this Certificate confirming they have not engaged in other forms of employment. Without a valid Certificate of Capacity, a worker will not be able to access weekly payments.
In addition to the above, a Certificate of Capacity will only be valid if it covers a period of no more than 28 days. The prescribed Certificate of Capacity form can be downloaded here.
Can I back-date a certificate of capacity?
There is no straightforward answer to this question because it depends on each worker’s circumstances.
When a worker is injured, they have to report their injury to their employer within 30 days of becoming aware of it. If they do not do so, their claim may be rejected.
In our experience, we find that workers rarely meet these reporting obligations for many reasons. Most commonly workers are afraid to lose their job or are concerned about the stigma of having a work injury. If a worker does not report the injury within 30 days, they can still proceed with making their claim.
Depending on how long after they make their claim, doctors will often be asked to back-date Certificates of Capacity so that the worker can obtain weekly payments backdated from when they ceased work or reduced their work hours due to their injury.
As long as the Certificate of Capacity is valid, there should be no issue back-dating it. If the certificate is back-dated, the reasons should be stated on the certificate.
The legislation allows for Certificates of Capacity to be backdated for a period of 90 days. Backdated certificates must only cover periods of no more than 28 days. The date of examination should be the date you examined the worker and not the date that the certificate was issued.
If you did not see the patient in the periods that you are asked to certify that they were unfit, you may recommend your patient obtain the certification from their previous doctor.
Do I require approval to refer my patient to allied health services?
Approval is not required for:
Allied health services other than those listed above do require approval the from WorkCover insurer and a written referral.
Can an allied health provider complete a certificate of capacity?
Yes, but the first certificate must be completed by a medical practitioner.
Subsequent certificates can be filled in by registered allied health providers including physiotherapists, chiropractors and osteopaths.
What if the insurer does not accept my request for a medical treatment?
Any rejections or refusals by the insurer can be challenged by the injured worker, not you.
A worker will need to make a request to the Accident Compensation and Conciliation Service (ACCS) to challenge the insurer’s decision. They generally have 60 days from the date of the decision to make this request, however this can be extended.
If the worker makes a request to the ACCS, they will then be required to obtain a report from their treating doctors to provide clinical justification for the treatment or expense sought. The insurer should fund this report.
WorkSafe takes a very long time to reimburse my clinic. Can I bill on Medicare?
You can use Medicare, but this may have consequences for the worker.
If a worker obtains common law damages, they may be required to repay any social security benefits obtained. This mainly includes Medicare, Centrelink and NDIS. The same repayment rule applies to private health insurance. Also, not having the insurer accept liability for treatment can be damaging to the worker’s claim.
Why is WorkSafe asking if the patient has work capacity?
Access to weekly payments depends on the patient’s work capacity.
The insurer may be asking you to comment on work capacity because they are reviewing the worker’s claim to determine whether they should continue making weekly payments or to terminate the worker’s entitlement.
At Polaris we are proud advocates for our clients and try to find ways to help them; not only fighting for their rights but also helping to educate them about the process and cooperating with the other members of the “village” to ensure our client gets back, as much as possible, to their pre-injury life.
If you have any questions about the Victorian workers compensation claim’s process for your own knowledge or have a patient that has recently injured themselves at work, on the road or in a public place, we are always happy to have a chat (for free) and help where we can.