‘Delay, Deny, Defend’; A Submission to NSW Workers Compensation Inquiry July 2025

22 July 2025

I very much welcome this Inquiry and would be happy to appear before your Committee to elaborate on and/or to clarify any other questions that you may have. I also have patients who would be more than willing to give evidence. I am a medical practitioner (GP) with a special interest and expertise in Workers Compensation (WC) and Compulsory Third Party (CTP) insurance since 1983. I have a current practice of at least 100 patients including a number with PTSD or stress related to workplace psychological trauma. Many of my patients are from socioeconomically disadvantaged or NESB backgrounds with the worst jobs and the highest injury rates.

My initial qualifications were in medicine and I am a Fellow the Royal College of Surgeons of England and have a Master’s degree in Applied Science in Occupational Health from UNSW. I had considerable experience in intensive care medicine and became active in the anti-tobacco movement because I realised that prevention was better and cheaper than cure. As an Australian Democrat MLC, 1998-2007, I initiated consequential inquiries into DOCS (now Dept. of Community Services), and Mental Health.

The key lesson from our successful tobacco campaign and those inquiries, and those since, is that money spent at the end-stage will not produce the most effective, efficient and equitable results. It is like having the only health services as intensive care units – no matter how much money is expended, no effective improvement will be produced, and costs will only be saved by reducing services, naturally leaving some people untreated, thus generating additional pain and suffering, as a consequence of shifting costs elsewhere. It would be tragic if this were to be the case with WC in NSW at the current time.

I am currently treating at least 6 long-term workplace psychological trauma patients where timely industrial relations (IR) interventions would have resolved the situation far more quickly, effectively and cheaply, had adequate advocacy been available. The chance of these workers’ compensation cases returning to work is
now frankly poor despite the fact that they have had the best psychological and psychiatric attention.

It might be noted that the legal system processes are so slow that in psychological cases the damage is often irreparable before they even have a hearing. My disadvantaged patients are often paid in cash and have less than 3 weeks before they are unable to pay for food and rent. In my extensive experience the time taken by insurers to approve cases and Nominated Treating Doctors (NTDs) requests is extremely destructive to patients. The denial of a large percentage of treatment requests is not monitored by the State Insurance Regulatory Authority (SIRA), despite my request for them to do so, and my providing evidence to them that up to 61% of treatment requests are denied. I have had a number of patients who have been strung along with
treatment denials for over 5 years; my longest was 14 years. (While it took 14 Years for my Workers Comp. patient to have back surgery approved, by then he was reluctant to return to work (RTW) as he feared being re-injured).

The UnitedHealthCare insurance executive who was gunned down in New York had the words, ‘Delay, Deny, Depose’ [sic] written on the cartridges from the fatal shots, a corruption of the title of the book, ‘Delay, Deny, Defend’, which critiqued the US health insurance industry. It has been reported that about 33% of the cases
were denied by his Company, one of the biggest health insurers in the USA. Delays are allowed in the NSW legislation. The percentage of denials of NTD treatment requests and the delay of approvals is not monitored, despite my requests for same. My own statistics for CTP, which I gave to the Hayne Royal Commission on Financial Services showed that in an unacceptably large percentage of cases treatments were denied by insurers. NRMA was the worst at 61%, Allianz at 43%, QBE 36% and Suncorp (GIO and AAMI) at 19%. Another source, which I am not at liberty to disclose had a sample size 10 larger than mine, with similar results. These figures were from 2016, but I do not believe the situation has changed significantly. It might be noted that
insurers have accepted a very high percentage of the claims, but then refuse the treatment of these claims without this being noted or sanctioned by the State Insurance Regulatory Authority (SIRA). It seems that SIRA functions as a senior insurance clerk to
minimise payouts, but not in any way as a patient advocate. Our Workers Comp system, which started as a means of getting top rate care for injured workers in NSW, is now examined in terms of ‘the impact of the bill on cost and economic conditions’. If our current situation is viewed merely as a cost to be minimised by the
insurers, employers and NSW Government, we can only expect to see ever-declining health outcomes for my patients and our NSW community. The best way to save costs is to optimise treatment.

You may be aware that John Nagle, the Ex-CEO of iCare was sanctioned for his use of algorithms. It would appear from an NTD medical perspective that treatments are still denied according to either an algorithm or a protocol to save money, and with no sanctions and so few disputed it is economically advantageous for insurers to deny on any pretext. The system is immensely adversarial. The medical notes are so available as to make ‘medical confidentiality’ a farce, yet insurer records are entirely opaque, protected by ‘legal privilege’. So while the NTDs have to justify any decision or even a long consultation, insurers do not have the same rule applied to them. Rehabilitation companies are chosen by insurers so that most of them see their client as the
insurer, rather than the patient. The ‘case managers’ (i.e. insurance clerks) who rotate frequently, try to use first name terms, but will not give their surnames as the callous messages that they have to deliver might put them in physical danger. NTDs are often not even informed of treatment denials- their correspondence is with the patient. Insurers seek to replace NTD medical management with insurance clerk management. Phone inquiries from NTDs are difficult and calls are not returned more often than not. Liaison between insurers and
employers also seems to be poor, communication being via rehabilitation professionals late in the case management.

Given my extensive medical knowledge and experience the solutions are:

1. To recognise that many of the Psychological workplace problems could be solved by a better IR disputes system. Perhaps doctors could directly refer for IR mediation in such cases;

2. To recognise that the problem of the WC system is that it is a dysfunctional medical insurance system which minimises short-term treatment costs, which perpetuates the medical problems while
maximising the administrative, investigative, medical reassessment and legal costs. The delays adversely affect outcomes. Improving treatment should be the first step in lessening costs;

3. To put the NTDs at the centre of the system, allowing them to organise treatments as happens with all other forms of health insurance. NTDs should also choose the rehabilitation professionals;

4. To have a significant treating doctor input to the management of iCare and SIRA, both at an administrative and a case management level;

5. To make SIRA collect and make public figures on treatment delays and denials from all insurers;

6. To make SIRA a true regulator that acts for patients and sanctions insurers for unreasonable decisions. Sanctions for unreasonable treatment denials should be able to be initiated by plaintiff solicitors and ruled in the Personal Injuries Tribunal to lessen treatment denials; and finally

7. To make insurer case records as transparent as medical records are, so that the basis of decisions and their timeliness and origins are transparent and accountable.

I attach two Appendices from my submission to the Hayne Royal Commission:

First, a 2- week survey of my patients to show the extent of insurer interference in reasonable and necessary treatments (Appendix 2);

Secondly, figures for radiology and specialist referral denials by insurers (Appendix 4).

Yours sincerely,
Dr Arthur Chesterfield-Evans M.B, B.S., F.R.C.S. (Eng.), M.Appl.Sci. (OHS), M.Pol.Econ.