Observations from the recent self-insured employers audits

We want to share with you four trends that we noticed during our recent audits of non-compliance found in claims.

Firstly, we found that there were insurers that had managed some permanent impairment (PI) for psychological injuries through Independent Medical Examiners (IME) rather than through the Medical Assessment Tribunals (MATs). All PI assessments for psychological injuries must be determined by the MATs.

Secondly, in some cases we found that disagreed Notices of Assessment were not being referred to the MATs. In all cases, workers have the right to have disagreed Notices of Assessment assessed by the MATs even if a Notice of Claim for a damages claim has been received.

Thirdly, whenever an insurer receives a medical report from an IME which suggests rejection of a claim or cessation of benefits, every worker is entitled to natural justice. This means that all evidence both supportive and adverse considered before a decision is made by an insurer should be released if requested by the worker. Some insurers act solely on the medical information provided by the IME without first seeking a medical report from the treating medical practitioner. This is contrary to section 6.6 of the Claims Management Performance Standards and Guidelines for Queensland Insurers.

Lastly, workers are not being given the right to disagree with industrial deafness degree of permanent impairment where the percentage does not lead to an offer after deducting the statutory 5% diminution of hearing. In these instances, a Notice of Assessment Approved Form 185.10 (Industrial Deafness) should be used and workers must given the opportunity to disagree with the degree of permanent impairment and have the matter referred to the Medical Assessment Tribunal for determination.

If you would like further clarification on any of these trends or would like to discuss anything further please do not hesitate to give us a call on 1300 361 235.