Local Government NSW HR Group Forum Investigations for Workers Compensation Claims

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1 Local Government NSW HR Group Forum Investigations for Workers Compensation Claims A discussion by Nick Tyson and Coralie Young of The Procare Group March 2013

2 Introduction Nick Tyson & Coralie Young The Procare Group: Established 1998 Services Investigators Geographical locations Other Services

3 Why Investigate? Intentions of stakeholders Not looking for opinion nor recommendations on liability/claims strategy. Information is key: - Lack of information - Dispute over key criteria - Things are not always as they seem Factual & surveillance services.

4 What is Involved? Factual Investigation: - Quasi-legal service - Without prejudice or opinion Activities include: - Interviews and statements - Scene inspection - Document gathering - Witness location

5 Factual Investigation Process When to consider a factual: - Conflicting evidence - Fraudulent claims - Psychological injury - Death claims - Significant injuries - Common law potential - Recovery of claims costs

6 Factual Investigation Process A typical factual investigation: - Instructions: phone contact and written referral - Allocation of referral - Contact with relevant parties - Conduct enquiries - Reporting - Invoice

7 Factual Investigation Psych Claims Not unlike investigation for physical claims. Greater focus on communicating the process to an injured worker. Exhaustive record of allegations & issues. Allow Employer every opportunity to respond to the allegations made. Note: this is not to be mistaken for investigating the Employer!! Policy & procedural records are crucial.

8 Factual Investigation Common Problems in the Field Misrepresent the organisation (service provider, Insurer, Insured). Poor communication between parties. Lack of preparedness. Information gathering not interrogation. Opinion, unsubstantiated conclusions. Incomplete (particularly with psych claims).

9 Surveillance Stereotypes Perception of Surveillance Services and Field Agents: - background and training - activities in the field - research/intelligence Boundaries of Surveillance in Insurance: - Information available - Government surveillance resources - Thorough and proactive - Legislative: Workplace Surveillance Act 2005 & Surveillance Devices Act 2006

10 Critical Requirements for Successful Surveillance Information Time - From the file - Independent research - Application by agents - Thorough/tenacious - No substitute - Identify correct subject - Cost v benefit

11 Process for Surveillance When to consider surveillance: - Fraudulent claims - Exaggerating symptoms & physical capacity - Common indicators from IW s - Other less intrusive methods of investigation have not provided suitable evidence.

12 Process for Surveillance A typical surveillance period: - Instructions: phone contact and written referral - Allocation of referral - Contact with relevant parties - Conduct enquiries - Updating, providing photographic schedules - Complete reporting process - Invoice

13 Surveillance Common Problems In The Field Insufficient background information available. Lack of communication with Insurer/Employer, particularly in light of the field difficulties faced. Compromised position. Multiple agents (or lack thereof).

14 How Can the Employer Assist? Exhaustive information: it is all relevant for the investigator's preparation. Clear instructions: timeframes; key issues; parties involved. Leverage existing relationship with parties involved. Communication. Invest the time.

15 How You Can Assist Full Name Previous Names Height Vehicle Details Weight Religion Maiden & Married Names Types of Drivers Licences Graduation Year and Location Hobbies Current Address Physical description Rehab Contact Country of Birth Schooling Marital Status Spouse/Partners Name Solicitor Details Sport Interests Claims History Dependants (including age and sex) Mobile Number Year of Immigration Registered Trade/Skill Sex Associates Home Phone Number Postal Address Languages Spoken Date of birth Injury type Former Employers NTD Name and Address Current & Former Occupations Financial Affairs/Loans Community Activities/Participation Distinguishing Features DOI Work Phone Number Claimant s Work Roster (if working) Known Appointments Hair Colour Anglicised & Country of Origin Names

16 Investigation in The New Legislative Environment Change in decision maker: WCC to Scheme Agent. Previously held views of the surveillance service in determining an injured worker s capacity. Surveillance is one of the best forms of evidence. Potential increase in the reliance on video footage of an injured worker s activities. Journey claims and the importance of detailed factual information.

17 Financial Impact of Investigations Inefficiency = Costs. Surveillance footage and Work Capacity Decisions. Journey claims now premium impacting. Thorough factual investigations for psychological claims.

18 Question Time Questions?

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