Lauren Kotevski, Clinical Psychologist and Team Leader, Navigator Group, and Joe Raciborski, Mental Health Consultant, Gallagher Bassett
In psychological injury claims, the clinical picture and the workplace account don’t always point the same way. This panel brought clinical and claims perspectives together to explore a simple but difficult question: when the clinical assessment and the claim decision differ, what needs to happen next?
The starting point is that clinicians and claims managers are asked different questions. A clinician asks whether a person is unwell and what they need to recover, and treats the whole person, including what pre-dates the job. A claims manager asks whether work caused the injury under the relevant legislation and what the scheme is responsible for. That is a legal test, not a clinical one. Neither question is wrong, but the worker sits between them and needs to understand both answers.
The panel identified three points where these views tend to pull apart. The same words can mean different things in clinical and scheme language. Whole-person care can extend beyond what the scheme funds. And a treatment relationship can sit uneasily alongside an independent review that reaches a different view.
Three scenarios brought these tensions to life. In the first, a worker on a performance improvement plan lodges a claim citing bullying. The panel’s view was that a diagnosis can be valid without settling causation, and that “bullying” should be treated as a reported mechanism to investigate rather than a conclusion. Just as importantly, a declined claim is not a judgement on whether someone’s distress is real.
In the second, long-standing anxiety emerges six months into an accepted claim. That history helps clinicians understand the full picture rather than invalidating the workplace experience, and its late appearance shouldn’t be read as dishonesty. The question becomes what it changes about the support needed now.
In the third, a treatment plan focused on rapport and emotional regulation lacks clear functional goals, and an independent examiner then reaches a different view. Clinical and functional goals don’t need to compete; the connection between them just needs to be made explicit. Workers also deserve to understand why an independent review is happening and what it means for them.
The discussion closed on practical steps. Explain what each assessment is for. Talk about treatment and scheme support early. Link clinical progress to everyday function, with clear review points. Explain differing opinions honestly to the worker. Pick up the phone when a plan or its progress is unclear.
There is no single fix. Both clinical and scheme obligations are legitimate, and the real work happens at the point where the worker gets stuck. Throughout the session, clear and direct communication between everyone involved kept coming up as the thing that makes the difference.