Harry prided himself on being a straight-forward man. He had worked in a bakery for many years but gave it up to move to the Blue Mountains. In his new town, he found work as a handyman at a local primary school.

Approximately eight months into his new position he was trying to move a plastic bin when a gust of wind caught it. The bin slammed into his shoulder, causing bruising and a dull ache.

The pain grew worse over the next few days. When Harry reported the injury three days later, the principal seemed sceptical. He asked why Harry had not told him sooner, then questioned how a bin could cause so much damage. He told Harry to get a doctor’s report to diagnose the injury.

At the doctors’ office, Harry was worried the GP might not believe him either. He did not mention prior shoulder problems, despite a football injury three years previously. The doctor did not think to ask about previous shoulder problems. The GP diagnosed a torn tendon and referred him to a surgeon.

The surgery helped somewhat but there was ongoing difficulty when Harry tried to do things above shoulder height.  No one visited Harry while he was in hospital and no one called him after the operation to see how he was going.

The claims manager received conflicting reports from the surgeon, the GP and Harry’s Medicare records.

She called Harry and confronted him with the inconsistencies, asking why he was lying. Harry felt attacked. He believed his claim would be dismissed if he admitted to his omission, so stuck to his story.

The claims manager ordered surveillance and further investigations. Harry did not return to work and no re-training program was put in place.  He spent months sitting at home, his tolerance for pain worsening as he slipped into depression.

The mental health issues eventually grew to the point where Harry was no longer considered fit for work. His claim is still ongoing two years later.

Lessons for return to work

When trust breaks down, achieving a successful return to work becomes complicated.

It can be difficult working with a client who appears to be withholding the truth. However, the return to work team can take steps to help foster trust between the parties.

Treat all claims as serious unless given firm evidence to the contrary

A major issue in Harry’s case was the sceptical response of his employer.

An employee whose story is treated with doubt will tend to view the entire process as hostile. That employee will see employers and claims managers as enemies rather than allies, making it far less likely they will co-operate.

The employer can help foster an open, trusting environment by approaching workers with a claim with an open mind. It is not the employer’s role to diagnose the medical issue or theorise about its causes. Providing support to the injured worker and encouraging medical assistance positions the employer as someone the worker can trust.
 

If doubts arise, address them with the worker in a sensitive, compassionate way

The claims agent was not necessarily wrong for doubting Harry’s story. However, her confrontational approach put Harry on the defensive. A person who feels threatened is more likely to clam up or lie further to protect themselves.

If an agent suspects a client is lying, a sensible approach is often compassion. Asking “can you help me understand these inconsistencies?” is more likely to get an honest response than approaching the employee as a liar.
 

Some dishonesty arises from a lack of understanding

Employees who lie do not necessarily do so because they are morally bankrupt. They may not realise the significance of the facts they are keeping to themselves. They may not understand how the process works. They may, like Harry, fear being sent back to work injured and empty-handed because of one prior incident.

If the claims agent had explained aggravation of a prior injury is compensable, Harry may have been more honest. Many claimants see the compensation system as a bureaucracy designed to pay out as little as possible. Helping the claimants understand the system and their options makes it easier for them to believe the system works fairly.
 

Exposing the “truth” sometimes does more harm than good

Compensation systems have a responsibility to spend money as efficiently as possible. Yet sometimes accepting a “borderline” claim may be more efficient than fighting it. The worker returns to work sooner while less money is spent on investigations and surveillance.   Disputed claims that are eventually accepted cost around six times as much as non-disputed claims.

Harry sensed suspicion about his injury and responded inappropriately by ‘hiding’ an earlier problem.  This led to further disbelief about his condition and a focus on claims management strategies at the expense of return to work focus.  Opportunities for meaningful rehabilitation and retraining were lost.

Harry is likely to remain out of work long-term, creating a greater burden on the public system.

A successful decision-making process weighs the impact of an investigation against the benefits of getting the person back to work.