When To Medically Review A Claim

It can often be difficult to work out whether to set up an independent assessment of the employee with a psychiatrist.

Medical evidence from the treating practitioner may be all that is required, particularly where the case is clearly compensable and the condition is merely a temporary adverse reaction to a given work circumstance.

Consider instead, having the Case Manager quickly commence rehabilitation (in fact, this is essential for 'stress' claims anyway), and as part of that process, have the employee assessed by a psychologist, if necessary.  This appears much less threatening to the employee.

Where the employee is already seeing a specialist, it might be useful to make an appointment to discuss the case with them.  Often, this means both Comcare and the doctor are clear on cause and diagnosis of the employee's condition.

However, there will be occasions when medical assessment by a specialist will be required.  This will include where there is:

• conflicting medical evidence; or

• information is generally lacking for which a decision can be made on the case.

When setting up an assessment, be very clear about what is expected from the examination and subsequent report.  Ask pertinent questions only.

It has been a habit in the past to send complete claim files to doctors, to read before they examine the employee.  While this certainly provides a clear history for the doctor, it can also be quite overwhelming for them to receive wads of paper, some irrelevant.

Instead, write a concise case summary, attach appropriate copies of medical and other evidence and keep the tone of all that is written objective and factual.  This way, there will be no signals or misconceptions picked up by the doctor.  The doctor can be fully acquainted with the case, can then examine the employee and document findings from a medical perspective.

Remember, the specialist is not making a decision on the claim.  He or she is providing a medical opinion on the basis of specialist expertise, examination of the employee, and the facts of the case presented to him or her.