 Disputed claims are more expensive.
Only dispute a claim if the issue is major, or return to work is not expected.
Get the facts yourself before you go ahead, don't rely on second hand information.
Engage and keep an active line of communication with the claims manager.
Document relevant information and ensure that it reaches the right people.
Communicate with the employee during the process.
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The Process
The decision to assess or dispute a claim is made by the insurer or claims agent. This is usually prompted by the employer.
While the claim is assessed it is held as "pending".
The process of assessing a claim includes:
| o | The treating practitioner |
| o | An independent source, such as an investigator or an independent medical review |
2. Understanding the rules that determine whether a claim should be accepted
3. Assessing the claim against the rules or legislation
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Challenges
There are many challenges in making a full assessment of a claim, and these challenges need significant attention to do the job properly. For a claim to be thoroughly assessed all relevant information must be gathered and sent to those assessing the situation.
To achieve this:
| o | Relevant staff need to be available, e.g. the supervisor in attendance on the day of the injury should not be on annual leave while relevant information is being gathered. |
| o | Information needs to be accurate and complete, for example, the absence of an injury report is not good evidence that an injury did not occur. |
| o | Disputed claims are more expensive. |
| o | Only dispute a claim if the issue is major, or return to work is not expected. |
| o | Get the facts yourself before you go ahead, don't rely on second hand information. |
| o | Engage and keep an active line of communication with the claims manager. |
| o | Document relevant information and ensure that it reaches the right people. |
| o | Communicate with the employee during the process. |
| o | The claimant often has a better recollection of what duties where undertaken. Supervisor input needs to be backed up by collaborating statements or worksheets, if available. |
| o | Treating practitioners are often slow to provide reports and may need follow up. |
| o | Independent assessors may not have all the relevant information available at the time of the assessment. For example, an independent medical assessor may see the patient and hear their side of the situation, but has not interviewed the employer. |
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Disputing a claim has a number of potential downsides
The compensation legislation broadly accepts most conditions when the employment may have contributed to it, even in a small way.
Disputing a claim has a number of potential downsides.
| o | The employee now has proof that the employer 'does not believe' them. For most people this will result in the need to 'prove' themselves; their injury and incapacity, that they are right and justified in their claim. |
| o | People who feel supported return to work sooner. Conversely, a person who does not feel supported will remain off work for longer. |
| o | People who are not believed are more likely to be distressed. In turn they are likely to have more investigations and medical treatment for their condition, with reduced chance that treatment will help. |
| o | While a claim may be denied after an assessment, the employee can use the dispute resolution system to have the decision reviewed. |
A claim that is initially disputed and then accepted leaves the employer with the:
| o | Costs of claim investigation - typically in the order of $2,000 |
| o | Increased likelihood of a prolonged case |
| o | Increased likelihood of an expensive claim
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 Data from the United States has shown that disputed claims cost approximately six times more than non disputed cases.
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Disputing a claim is appropriate in some circumstances:
Disputing a claim is appropriate in some circumstances.
| o | The employee / employer relationship has broken down and there is good evidence the claim is not justified. |
| o | Where there is clear and solid evidence the condition occurred outside of work - e.g. the treating doctor clearly indicated the injury occurred in non compensable circumstances. |
| o | The injury occurred with a prior employer and there has not been an aggravation with the current employer. |
| o | The company is closing down, or the person is being retrenched / terminated. |
Before going ahead with a claim dispute it is worth getting the facts straight. If a supervisor says the person was not working on that job a month ago, get supporting evidence e.g. work sheets or other collaborating evidence. It is easy and common for misunderstanding to occur, and the consequences can be substantial. Get it right from the start.
The pros and cons of disputing a claim should be made clear to those who suggest doing so. Disputing a claim can add $10,000 to $50,000 in claims costs if it is not very well managed. This occurs commonly.
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Next:
How to Manage Disputing a Claim
