A glossary for injured workers Who s who in the claims process

Transcription

1 A glossary for injured workers Who s who in the July 2013

2 Who s who in the A glossary for injured workers About us 1 Talking your language service 2 Key contacts during the 3 About the roles in the 4 Allied healthcare professionals 5 Case manager 5 Clinical panel 6 Conciliation service 6 Dispute manager 7 Employers 7 Health management specialist/medical advisor 8 Health and safety representative/delegate 8 Impairment benefit specialist 9 Independent impairment assessor 10 Independent medical examiner 10 Injury management advisor 11 Medical panels 11 Medical practitioner 12 Occupational rehabilitation provider 12 Ombudsman Victoria 13 Return to work coordinator 13 Self-insured employers 14 Team manager 14 Technical manager 15 Unions 15 Union Assist 15 WorkSafe Advisory Service 16 WorkSafe Agent 16 WorkCover Assist 17 For more information 18 WorkSafe Advisory Service 18 WorkSafe Agents 19 WorkSafe Victoria is a trading name of the Victorian WorkCover Authority. This glossary outlines the roles of the people and organisations that you may encounter during the. Should any differences arise over the interpretation of the content of the glossary and the law, the law applies. WorkSafe wants you to make informed decisions and recommends obtaining independent advice on issues from either your union or lawyer prior to making decisions that have legal implications. The information contained herein is protected by copyright. However, WorkSafe encourages the free transfer, copying and printing of this glossary. First published July 2007.

3 About us If you have a work-related injury or illness, whether it is a new condition or a recurrence, aggravation or deterioration of a pre-existing injury or illness, you may be eligible to claim for benefits under the Victorian workers compensation legislation. To help you with the, WorkSafe created this glossary to explain the people and organisations you may encounter when you lodge a WorkSafe insurance claim. This glossary will help you understand their roles and what you can expect of them during the. This brochure is a supplement to Introducing WorkCover: A guide for injured workers and How to make a WorkCover claim: A guide for workers. WorkSafe Victoria The Victorian WorkCover Authority, operating as WorkSafe Victoria (WorkSafe), is responsible for administering Victoria s workers compensation scheme and legislation. WorkSafe provides fair and appropriate compensation to workers for work-related injuries and illnesses under the legislation. The Victorian workers compensation scheme is a no-fault scheme, meaning that an entitlement to compensation is not linked to who is responsible for the injury or illness. Whether a person is entitled to compensation will depend on whether they meet the criteria for eligibility set out in the legislation, including the nature of their injury or illness and how it occurred. WorkSafe also provides guidance and support on Victoria s occupational health and safety legislation and enforces compliance with this legislation. We also aim to ensure the health and safety of people at work, and reduce the social and economic cost to the Victorian community of work-related injuries and illnesses. WorkSafe Victoria Who s who in the A glossary for injured workers 1

4 Talking your language service WorkSafe has introduced a new multilingual telephone service called Talking your language. This service helps to ensure that everyone receives the same level of information and assistance to recover from a workplace injury or illness, no matter what language they speak. The language service offers injured workers (and their representatives) an opportunity to listen to pre-recorded information in their own language about: how to make a claim for their work-related injury or illness, and what support they can expect to receive to help them recover from their injury. Callers are also offered the option of having their call transferred to the WorkSafe Advisory Service with an interpreter ready to assist, during normal business hours. Languages available Languages currently available include Arabic, Cantonese, Greek, Italian, Macedonian, Mandarin, Serbian, Spanish, Turkish and Vietnamese. You can access this service by calling the relevant number below Where to get more information If you need more information about the Talking your language service, please phone the WorkSafe Advisory Service on freecall Who s who in the A glossary for injured workers WorkSafe Victoria

5 Key contacts during the Key contacts and people you may encounter during the Your key contacts Employer/self-insured employer Return to work coordinator Case manager Medical practitioner Allied healthcare professional Dispute contacts Conciliation service Union Assist WorkCover Assist Dispute manager Solicitor Medical panels Ombudsman Victoria At the WorkSafe Agent Case manager Injury management advisor Health management specialist Technical manager Dispute manager Team manager Impairment benefit specialist WorkSafe Victoria WorkSafe Advisory Service Clinical panel Independent parties Occupational rehabilitation provider Unions Independent medical examiner Independent impairment assessor Health and safety representative You will most likely encounter the key contacts listed above during your claim. However, you may also deal with people at the WorkSafe Agent as well as other independent parties and dispute contacts. WorkSafe Victoria Who s who in the A glossary for injured workers 3

6 About the roles in the Every WorkSafe insurance claim is different. You may come across many or just a few of the roles listed alphabetically below. After a work-related injury or illness and lodging a WorkSafe insurance claim, you are likely to come into contact with representatives from: your employer direct manager or return to work coordinator the insurance company (known as the WorkSafe Agent) you may deal with many people, but your main point of contact will be your case manager health practitioners such as your doctor or other healthcare professionals. In some instances you may come into contact with: WorkSafe the regulator of the Victorian workers compensation scheme independent medical examiners dispute resolution services. Where this glossary refers to the functions and responsibilities of WorkSafe Agents, in most cases these functions and responsibilities also apply to self-insured employers. 4 Who s who in the A glossary for injured workers WorkSafe Victoria

7 Allied healthcare professionals Independent party After your work-related injury or illness you may visit an allied healthcare professional such as a physiotherapist or psychologist. Allied healthcare professionals are responsible for the treatment and rehabilitation of your work-related injury or illness. They will focus on: helping you get back to work or stay at work helping you to return to your daily activities providing you with ways to manage your injury or illness monitoring your progress and outcomes talking to your medical practitioner, employer and WorkSafe Agent about your progress. You can choose which allied healthcare professional you use providing they are registered with WorkSafe. When you visit an allied healthcare professional, you should provide them with information about your claim, employer, WorkSafe Agent and work duties. Case manager Employed by your WorkSafe Agent An Agent will assign you a case manager to manage your claim. A case manager is the primary contact for you and all others involved in your claim, such as your medical practitioner, allied healthcare professionals, employer, lawyer and any other parties. The case manager has ultimate accountability for the management of a claim. From the start of the claim they are the main contact for you and your employer. A case manager will: coordinate payment of your medical expenses process your weekly payments assist you with your return to work program by contacting relevant parties develop strategies to promote an early return to work and review offers of suitable employment conduct case conferences and mediate with relevant parties review requests for treatment and manage your treatment program. The case manager may also be referred to as the injury claims consultant. WorkSafe Victoria Who s who in the A glossary for injured workers 5

8 Clinical panel Independent party, but engaged by WorkSafe to provide specific services The WorkSafe clinical panel consists of medical and allied healthcare professionals including medical practitioners, pharmacists, psychologists, chiropractors, osteopaths and physiotherapists. It also conducts clinical reviews to support medical and allied healthcare professionals in their management of your work-related injury or illness. The panel ensures that treatment is appropriate, clinically justified, and helps stay at or return to work. You and your healthcare professionals are advised in writing prior to a clinical review, which involves peer-to-peer phone contact between panel members and your healthcare professionals to discuss your current and future treatment requirements. Conciliation service Employed by government and independent of WorkSafe The conciliation service, also known as the Accident Compensation Conciliation Service (ACCS), deals with disputes about WorkSafe insurance claims. The ACCS is independent of WorkSafe, Agents, employers, solicitors and unions. Conciliation officers are government appointed on the Minister s recommendation. The ACCS is a free service that can help resolve your dispute through a conciliation conference. If your dispute is not resolved through the ACCS you may proceed to a court hearing. If your dispute proceeds to the ACCS you may need to provide information such as medical records that support your case. For more information or to get a Request for Conciliation form, contact the ACCS on freecall or (03) , or visit 6 Who s who in the A glossary for injured workers WorkSafe Victoria

9 Dispute manager Employed by your WorkSafe Agent The dispute manager is the Agent s representative at a conciliation conference. They have the appropriate experience and knowledge to deal with the conciliation process and are willing to discuss all disputed issues in a constructive way. You will meet the dispute manager at the conciliation conference. They may also be referred to as a dispute resolution manager. Employers Independent party Your employer should be involved from the moment your work-related injury or illness occurs. Following a work-related injury or illness your employer should support you in seeking medical treatment. Your employer will participate in rehabilitation and return to work planning including activities with you and your doctor. It is the duty of your employer to maintain a register of workplace injuries or illnesses. Your employer is also obliged to: appoint a return to work coordinator who will develop and implement a return to work plan support and monitor your progress through the return to work period develop and implement a risk management program, and develop and implement an occupational rehabilitation program. If your claim for weekly payments is accepted, your employer has a legal obligation for approximately 12 months to: offer you suitable duties if you have a capacity to work re-employ you in the same or equivalent pre-injury position once you are no longer incapacitated. Your employer may be a self-insurer or covered by the Victorian workers compensation scheme. If your employer is a self-insurer they will manage their own WorkSafe insurance claims in accordance with Victorian workers compensation legislation. See the self-insurers section on page 19 for more details. WorkSafe Victoria Who s who in the A glossary for injured workers 7

10 Health management specialist/medical advisor Employed by your WorkSafe Agent Health management specialists are doctors who work for WorkSafe Agents. They provide medical advice to case managers about injury management and return to work. A health management specialist may contact your treating healthcare professional to clarify your condition, treatment and capacity. They are also a point of contact for your medical practitioner. Health and safety representative/delegate Employed by your employer The role of the Health and Safety Representative (HSR) is to raise occupational health and safety issues with their employer on behalf of their designated work group. The HSR can help determine the cause of an injury and how to minimise the risk of it happening again. They can be a useful source for generating ideas about suitable employment options for an injured worker who is not ready to return to their preinjury duties and can help modify a job to suit an injured worker s needs. Development and implementation of the risk management plan, and identification of health and safety issues arising from the injured worker s return to work plan are areas where the HSR can also make a valuable contribution. 8 Who s who in the A glossary for injured workers WorkSafe Victoria

11 Impairment benefit specialist Employed by your WorkSafe Agent An impairment benefit is a lump sum payment that is separate to your entitlement to weekly payments or medical and like expenses. The role of the impairment benefit specialist is to determine the liability (legal responsibility) for each work-related injury or illness claimed and the level of permanent impairment arising from that injury or illness. If liability is accepted for one or more injuries or illnesses, or if more information is required to determine liability, the impairment benefit specialist will ask you to attend at least one independent impairment assessment. This assessment will be undertaken by an independent impairment assessor. The impairment benefit specialist uses the outcome from this assessment to assist them determine your entitlement to an impairment benefit, if any. They will issue you with a Notice of Liability and Entitlement outlining: the work-related injuries and illnesses for which liability is accepted how they determined the degree of permanent impairment how they calculated your impairment entitlements (if any), and your rights to review this outcome. When you have responded to the Notice of Liability and Entitlement, the impairment benefit specialist will either refer the matter to: the Accident Compensation Conciliation Service (if you dispute liability or calculation of entitlement), or an independent medical panel (if you dispute the degree of permanent impairment). During this process the impairment benefit specialist will be in contact with your employer and if applicable, with your lawyer. WorkSafe Victoria Who s who in the A glossary for injured workers 9

12 Independent impairment assessor Independent party, but engaged by WorkSafe to provide specific services Assessments of impairment are conducted by doctors called independent impairment assessors. These doctors are specially trained in how to apply the American Medical Association Guides to the Evaluation of Permanent Impairment (4th Edition) and other guidelines specified in Victorian workers compensation legislation, to your injury or illness. You are required to attend an impairment examination with an independent impairment assessor if liability is accepted for one or more of your claims. If you have more than one work-related injury or illness arising from the same incident at work you may need to attend more than one impairment examination. The assessor may, at times, be asked to provide comment to assist the impairment benefit specialist determine liability and your entitlement to an impairment benefit. Independent medical examiner Independent party, but engaged by WorkSafe to provide specific services Independent medical examiners are medical practitioners approved by WorkSafe, who must meet strict criteria. They are not employees or representatives of WorkSafe, WorkSafe Agents or self-insurers, however they are paid by WorkSafe for the independent medical advice they provide. An independent medical examiner s role is to review your medical condition and/or treatment and provide WorkSafe Agents with an opinion about your injury or illness. They do not provide you with treatment. Medical opinions that independent medical examiners give to WorkSafe Agents or self-insurers may help them determine whether you are entitled to weekly payments and/or medical services. You may be required to attend an independent medical examination conducted at regular intervals by registered medical practitioners such as general practitioners, surgeons or physiotherapists. 10 Who s who in the A glossary for injured workers WorkSafe Victoria

13 Injury management advisor Employed by your WorkSafe Agent The injury management advisor provides injury management strategies and advice to case managers about treatment and return to work plans. The injury management advisor also assists WorkSafe Agents in making appropriate decisions on injury management and return to work. The injury management advisors can act as a point of contact for your healthcare professionals or treating medical practitioner. Medical panels Employed by government and independent of WorkSafe If there is a disagreement about aspects of your work-related injury or illness, this may be referred to an independent medical panel by a conciliation officer, a court and in some circumstances by a WorkSafe Agent or self-insured employer. The role of the medical panel is to make an assessment of your condition and give an opinion to the court, body, organisation or person requesting this information. Medical panel doctors are independent government appointments on the Minister s recommendation and are independent of WorkSafe, WorkSafe Agents, employers and self-insurers. You may be required to provide copies of your x-rays, scans and reports to the medical panel for assessment. You will receive advance notice of what information is required. You should contact the medical panel if you are unable to obtain a test result or report which you believe should be considered by the medical panel. In some instances, you may be asked to sign a consent form so the medical panel can access this information. The medical panel may consider, and provide an opinion on, one or more of the following medical questions: the nature of your medical condition your incapacity for work and whether it is permanent what other work you may be able to perform whether your current treatment is appropriate for your work-related injury or illness whether your employment was a significant contributing factor to your workrelated injury or illness the extent and likely prognosis of your condition whether your incapacity for work is due to your work-related injury or illness your level of permanent impairment for a potential impairment benefit or common law claim. WorkSafe Victoria Who s who in the A glossary for injured workers 11

14 Medical practitioner Independent party After your work-related injury or illness you may visit your medical practitioner who will assess your work capacity and may provide you with a Certificate of Capacity. Medical practitioners are responsible for the overall management of an injured worker s injury or illness. This includes primary care of the injury or illness, making an appropriate diagnosis and referrals, monitoring progress and outcomes and facilitating your return to work. When you visit your medical practitioner you should provide them with your basic information including your claim, employer and Agent. Occupational rehabilitation provider Independent party but engaged by WorkSafe to provide specific services Occupational rehabilitation providers are approved under Victorian workers compensation legislation to provide a range of return to work services to complement treatment provided by your medical practitioner or healthcare professional. Occupational rehabilitation services are designed to get you back to work quickly and safely. The details of at least three suitable occupational rehabilitation providers will be supplied to you when you receive notice from the WorkSafe Agent or self-insured employer that your WorkSafe insurance claim is accepted. You will need to choose one provider from this list. Providers on this list are included based on the type of occupational rehabilitation service required, your injury and where you live. In some instances it will not be possible to provide a list of three providers. Occupational rehabilitation services offered will differ depending on whether you can return to your pre-injury employer or whether you need to secure a new job at a new workplace. For more information refer to Occupational Rehabilitation Services: A Guide for Workers. 12 Who s who in the A glossary for injured workers WorkSafe Victoria

15 Ombudsman Victoria Employed by government and independent of WorkSafe The Ombudsman is an independent statutory officer who has jurisdiction to investigate complaints about administrative actions of WorkSafe, WorkSafe Agents and self-insured employers. The Ombudsman can also examine the processes and procedures used by WorkSafe and WorkSafe Agents in handling complaints. It cannot review the merits of a specific decision but can review the administrative actions taken to make that decision. If you think you have been treated unfairly you may make a complaint to Ombudsman Victoria. Before complaining you should first try to resolve your problem directly with the WorkSafe Agent or WorkSafe. All services provided by Ombudsman Victoria are free. Contact Ombudsman Victoria on freecall or at Return to work coordinator Engaged by your employer The return to work coordinator is a staff member appointed by your employer to assist in your return to work and maintain an effective and supportive relationship with you. In consultation with you and your treating health practitioner, they will develop an individual return to work plan and when you are certified as medically fit to return to work in some capacity, they will make an offer of suitable employment. They will manage, implement, monitor and progress the return to work plan and offer suitable employment as your capacity improves. They will also ensure that where necessary, access to occupational rehabilitation services is available. The return to work coordinator also acts as a link between you and other parties such as work supervisors, work colleagues and treating health professionals. WorkSafe Victoria Who s who in the A glossary for injured workers 13

16 Self-insured employers Independent party If your employer is a self-insurer, it is approved by WorkSafe to manage its own workers compensation claims and has full responsibility for meeting its claims liabilities. If you are a worker of an approved self-insurer, your primary point of contact for WorkSafe insurance claims should be your employer. Workers of self-insurers have the same entitlements to benefits as workers covered by the Victorian workers compensation scheme. Self-insurers must comply with Victorian workers compensation legislation and regulations and any terms and conditions of approval imposed on them by WorkSafe. More information including a list of currently-approved self-insurers can be found online at worksafe.vic.gov.au by clicking on Insurance and Premiums. Where this glossary refers to the functions and responsibilities of WorkSafe Agents, in most cases these functions and responsibilities also apply to self-insurers. Team manager Employed by your WorkSafe Agent The team manager is directly responsible for overseeing a team of case managers to ensure delivery of effective and efficient case management of WorkSafe insurance claims. Team managers assist you by ensuring that your case manager is handling your claim in an appropriate manner. You are most likely to speak with a team manager if you would like to escalate an issue or complain about the management of your claim. The team manager may also be referred to as a service manager. 14 Who s who in the A glossary for injured workers WorkSafe Victoria

17 Technical manager Employed by your WorkSafe Agent The technical manager is responsible for assisting the case manager undertake the technical aspects associated with managing a claim. They also assist you by ensuring that the decisions made by the case manager are technically and legally correct. In most circumstances you won t have direct contact with the technical manager, however, for more complex matters the technical manager may contact you or your employer. Unions Independent party Most unions provide free assistance to their members with issues or disputes about WorkSafe insurance claims. They can also support your return to work and ensure your workplace is safe when you return. You should contact your union for more information. Union Assist Independent party Union Assist is a free service set up and run by the Victorian Trades Hall Council to help their members with dispute resolution. For more information call (03) WorkSafe Victoria Who s who in the A glossary for injured workers 15

18 WorkSafe Advisory Service Employed by WorkSafe The WorkSafe Advisory Service is a free service that provides: return to work, rehabilitation rights and obligations information help to resolve issues that could not be overcome with the WorkSafe Agent advice on your WorkSafe insurance rights, including health and safety and what to do if you are injured or ill information and advice on general occupational health and safety enquiries, including reporting of unsafe workplaces and incident notification employer advice on WorkSafe insurance, and access to all WorkSafe publications. You can contact the WorkSafe Advisory Service on freecall WorkSafe Agent Independent party but engaged by WorkSafe WorkSafe engages authorised WorkSafe Agents to manage your claim and make decisions about your entitlement to compensation, e.g. weekly payments, medical and like expenses etc. to be paid to you. Unless your employer is an approved self-insurer they are required to choose one of these authorised agents as their WorkSafe Agent. The functions performed by WorkSafe Agents include: managing your claims to ensure you receive appropriate entitlements assisting your return to safe and sustainable work, and collecting employer premiums for WorkSafe injury insurance. Your Agent will work with you and your employer to ensure that you receive appropriate assistance with your claim. Contact details for all Agents appear at the back of this brochure. If you are unsure which Agent is managing your claim, please contact the WorkSafe Advisory Service on freecall Who s who in the A glossary for injured workers WorkSafe Victoria

19 WorkCover Assist Employed by WorkSafe WorkCover Assist is a free service provided by WorkSafe for workers requiring assistance during the dispute resolution process. WorkCover Assist can: give you advice on issues relating to your WorkSafe insurance entitlements, subject to the dispute resolution process provide support and assistance during the dispute resolution process, simplifying the process for you attend conciliation conferences with you at the Accident Compensation Conciliation Service and act as your advocate provide a vast amount of knowledge and experience in workers compensation matters. You can contact WorkCover Assist on (03) WorkSafe Victoria Who s who in the A glossary for injured workers 17

20 WorkSafe Victoria Advisory Service Phone (03) Toll-free Website worksafe.vic.gov.au WorkSafe Agents ALLIANZ Workers Compensation (Vic) Limited Freecall: CGU Workers Compensation (Vic) Limited Freecall: Gallagher Bassett Services Workers Compensation Vic Pty Ltd Freecall: QBE Workers Compensation (Vic) Limited Freecall: Xchanging Pty Ltd Freecall: For information about WorkSafe in your own language, call our Talking your Language service WorkSafe Victoria is a trading name of the Victorian WorkCover Authority VWA1103/11/07.13