10 September 2018

Talking of bullies … meet the insurers!

KnowCents Medicolegal

A Sydney doctor is demanding an investigation into insurance companies over alleged bullying of doctors and neglect of patients in workers compensation and traffic accident cases.

Dr Arthur Chesterfield-Evans is asking the Royal Commission into Misconduct in the Banking, Superannuation and Financial Services Industry to put the insurers’ practices under the spotlight.

He says the industry’s actions in short-changing customers are “wilful, unchecked and very similar to those of the recently revealed conduct of the banks”.

“They arbitrarily refuse treatments, investigations or referrals with no real respect or concern for patients or treating doctors,” he writes in a detailed submission to the commission, presided over by former High Court judge Kenneth Hayne.

Dr Chesterfield-Evans, whose GP practice focuses on workers compensation (WC) and compulsory third-party (CTP) insurance cases, says it’s as if the insurers have a motto of “deny, delay, dispute”.

“The systematic bullying of treating doctors, the continual demands for justification or information for every treatment requested, and the capricious and venal denials are what makes a considerable percentage of doctors either modify their management against the patients’ interests or refuse to do the work at all,” he writes.

The long-serving public-health activist, who sat in the NSW Upper House for nine years as a member of the Australian Democrats, says doctors are undermined by insurers’ tactics.

In refusing treatments, the companies allege that there is nothing wrong with the patient or that the patient had the condition prior to the accident, he writes.

They may claim that a tiny anomaly on an X-ray was evidence of prior disease, and the patient’s pain was not caused by the accident, even if the patient was working before the accident and unable to work after it. 

He says insurers have a history of trying to pressure doctors to change the wording in medical reports and go to the trouble of writing to doctors demanding previous notes to seek evidence of prior injury.

“Doctors usually do not have notes relating to injuries that have not yet occurred, but if they do not reply, the insurers say that they are waiting for the information and naturally will not pay until they receive it,” he writes.

“The delay suits them and sometimes the patients go broke waiting for treatment, quite apart from the pain and suffering of delayed treatment.” 

With patients in severe pain and at risk of becoming addicted to pain-killers, doctors try to get them treated more quickly through Medicare and private health insurance – which becomes a cost which may not be recompensed, he says.

When files are demanded, the whole file is demanded, he adds.  When one doctor billed an insurer for the time spent to remove non-recompensable issues from a patient’s records, the company refused to pay.

The commonest injuries he sees are whiplash and back pain caused by road accidents. He also cares for patients discharged from hospitals after more major injuries. 

“In my experience insurers in the NSW WC and CTP systems routinely refuse treatments to injured people who are entitled to these treatments and cause an immense amount of pain and suffering,” he writes.

Dr Chesterfield-Evans says that the State Insurance Regulatory Agency of NSW seems never to censure the insurers for not paying claims.  

“This systemic culture of denial has allowed insurers to make more profits than they had anticipated and for the NSW government to actually take a ‘dividend’ from the CTP scheme of $950 million.” 

In his practice, Dr Chesterfield-Evans has calculated that insurers refused approximately 16% of his GP consultation billings for WC and CTP patients in the 18 months to December 2017.

In a two-week period, 76% of these patients had investigations, referrals or treatments denied by insurers. “This makes normal treatment almost impossible and renders the whole schemes little more than a scam,” he says.

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1 year 2 months ago
I too have been in practice 30 plus years and have seen colleague s bullied , and accused of lying by insurance companies to the point that many of my colleagues are refusing to do any 3rd party cases or tell the patient that they will not be writing reports. I have had patients designed referral to a pain specialist- this takes the path of constantly avoiding he issue . It seems to me that the constant procrastination is part of the training! Another tactic seems to be moving their staff constantly so that they never know their cases and… Read more »
Jennifer Davis
Jennifer Davis
1 year 2 months ago
I have been in practice for over 30 years and have seen huge amounts of frustration and suffering caused by deliberate delays in approval for investigations and treatment. I saw one helicopter pilot’s straightforward case delayed to the point he lost currency of all his certificates and lost his employment as a helicopter pilot for emergency evacuations . This was a huge waste to the community of his training and professional experience. He was in unnecessary pain for a long time and not surprisingly became depressed, adding to his own suffering, the need for psychiatric care and to the cost… Read more »