RESEARCH ARTICLE

 

Rehabilitation and work reintegration within the disability claims management process: A South African Private Insurer Perspective

 

 

Dineshree Reddy^{I, II}; Pragashnie Govender^III; Deshini Naidoo^IV

^IOperations Manager Disability and Underwriting, Group Risk at Discovery Limited, Gauteng, South Africa. https://orcid.org/0009-0001-0324-628X
^IIOccupational Therapy, School of Health Sciences, University of KwaZulu-Natal, South Africa
^IIIOccupational Therapy, School of Health Sciences, University of KwaZulu-Natal, South Africa. https://orcid.org/0000-0003-3155-3743
^IVOccupational Therapy, School of Health Sciences, University of KwaZulu-Natal, South Africa. https://orcid.org/0000-0001-6276-221X

Correspondence

 

 

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ABSTRACT

BACKGROUND: Maintaining or promoting employment in the presence of disability or reducing the impact of disability on employability should be the adopted focus to decrease the negative impact that disability has on the economy and just as important on the livelihood and well-being of exposed insured individuals. Group risk disability insurance protects an employee's income when illness or injury result in work disability. To achieve this, factors that promote the success of rehabilitation and support for return-to-work of employees following illness and injury need to be understood from an insurance perspective.
OBJECTIVES: To explore principles of disability claims management during the rehabilitation and work reintegration stage using a multi-stakeholder approach for the purpose of successful return to work.
METHODS: An exploratory qualitative design was used to collect data via semi-structured interviews with 26 purposively selected participants. Interviews were audio-recorded, data were transcribed and analysed thematically. Qualitative research was used to understand the necessary role players in the work reintegration process, factors that hinder and promote work reintegration and best practice principles for Disability Claims Management (DCM).
RESULTS: Three themes emerged from the study; (i) role players and their functions with collaboration is integral to disability claims management, (ii) various factors promote and restrict return-to-work planning, and (iii) best practice principles in the DCM pathway that promote return-to-work. These principles include behavioural economics as the central principle, with resource identification and competency, governance, role engagement and education and awareness as supporting principles.
CONCLUSION: Collaborative and integrated approaches by role players within a workers' family unit, health system, employer structure and insurance compensation are required for positive return-to-work outcomes. The various role players are responsible for creating policies, structures, intervention strategies, and environments that foster return-to-work.
IMPLICATIONS FOR PRACTICE
• An integrated approach is required for optimal RTW outcomes as employers' policies restrict work integration.
• A collaborative approach by all role players involved in DCM, focusing on positive RTW outcomes is required in the RTW process
• Occupational therapists can influence employer incapacity and disability policies in order to keep people employed and productive in the presence of medical conditions with the application of reasonable accommodations where necessary.
• Occupational therapists are suitably positioned to outline workplace environment and other supports required to guide and support employees through rehabilitation and RTW and in ensuring that employees who can remain at work while on a partial or fully insured benefit, can engage optimally in aspects of work function.

Keywords: vocational rehabilitation, work function, disability claims management, behavioural economics, work disability, role-player collaboration, return-to-work

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INTRODUCTION

Work disability most often refers to the permanent inability to work, but it can also include temporary inability to work, sick leave, or reduced work hours¹. Work disability is a crucial health outcome measure of critical lifestyle importance to workers who suffer injury and chronic illness. Work disability is costly for workplaces, families, and society, and incurs enormous expenditures every year². Work reintegration forms a component of work disability management and is oriented towards returning an individual to work following injury or illness. Work reintegration includes treatment, rehabilitation, retraining, and early return to work (RTW) procedures³. One in 13 employees globally claim disability benefits⁴, reinforcing the frequency of insurance losses and necessitating strengthening insurance disability claims reserves⁵. Maintaining or promoting employment in the presence of Work disability is required to decrease the adverse effects on employees' economic livelihood and well-being. The ensuing review explores disability management (DM) in the context of rehabilitation and RTW following the admission of a disability claim within Group Risk Insurance.

In terms of disability claims management, employers provide group risk disability insurance to their employees as part of the employer's risk management strategy to provide income to employees if health or injury impacts workability. Based on the first author's background in the insurance industry, it seems evident that the responsibility for managing employees after illness or injury is a shared effort between the insurer and the employer. Consequently, Disability Claims Management - when an insured benefit is in effect - can be seen as a collaborative intervention approach between the employer and the insurer. Disability Management is also viewed as Disability Claims Management and is not limited to claims processing under the specific disability benefits plans, but includes the active management of claims. Disability Management is proactive and aimed at recovery and work reintegration, including the employer, the worker, private or state insurers, and healthcare professionals^3,6.

Role players in Disability Management (DM)

Teamwork, establishing expert interactions within a multidisciplinary team (MDT) including the employer, employee or employee's representative, and Disability Management (DM) rehabilitation service providers are essential for DM⁷, with co-operation between all stakeholders³ crucial. The interdisciplinary DM team may include employer representatives (safety managers, occupational health nurses, risk managers, human resources personnel, and operations managers), labour union representatives, the worker's treating physician, a rehabilitation case manager, an onsite physical or occupational therapist, the employee⁸ and insurer⁴. HR managers are responsible for developing organisational policies and providing advice or guidelines on labour issues to manage an employee with impairment or disability in the workplace⁸. Occupational therapists are essential in providing RTW recommendations, strategies, and job coaching⁹.

It has become common for insurers in South Africa to employ occupational therapists as claims assessors to ensure robust assessments considering the occupational impact of medical diagnoses¹⁰. The importance of disability claims assessors as role players in DCM has been identified as a central and integral factor in insurers' managing and improving claims experience. Assessment teams with more experienced assessors yielded higher claims termination rates than teams with less experienced assessors¹⁰

In 2012, Reinsurance Group of America (RGA) conducted a survey which cited that 43% of South African insurers did not employ rehabilitation services to manage disability claims. This was in marked contrast to the other regions surveyed (Australia, North America, and the UK). Over 80% in each market reported using rehabilitation services to manage disability claims¹⁰, indicating the need to strengthen RTW programmes and their uptake within the South African context. There is a growing need for DM rehabilitation service providers to be included in effective programmes in various workplace environments so that accommodations and RTW services can be managed efficiently and appropriately to allow employees with functional limitations in the workplace to remain employed^7,11.

Essential DM concepts and strategies

DM programmes that include a blended approach, that is, between organisations with proactive RTW interventions and individuals, limit the incidence of disability¹². The blended approach outlines integrated corporate leadership with management collaboration and timely RTW for employees, concepts essential in formulating and implementing a successful DM strategy⁸. Early during a claim, the insurance representative, treating doctor, and insured must help determine risk factors and barriers to returning to work, align expectations, and collectively agree on personalised interventions for optimal health recovery¹³.

Factors that impact Disability Management

Employers who assume ownership and responsibility for injured worker reintegration and worksite accommodations frequently use Disability Management (DM) programmes that include components for optimal disability management⁸. These components include an accurate understanding of the types of injury and illness that occur, the employer's timely response to the injury or illness, clear administrative policies and procedures, and the effective utilisation of health care and rehabilitation services⁸. Disability management policy secures care for valued personnel; affected workers are back on the job as quickly as feasible to preserve productivity with meaningful employment, improve staff morale, reclaim their previous income levels, and improve the social well-being of the individual within the family unit⁴. Employees are central to the reintegration process; a positive attitude toward work, a strong relationship with their employer, and appropriate physical and mental stress levels improve RTW¹⁴, including motivation to RTW¹⁰. A supportive, caring, and empathie supervisor with co-worker support⁹ and health-related messaging from family and friends, often referred as "significant others", is a significant factor influencing recovery and RTW¹⁴. The stigma associated with disability and impairment negatively impacts the disability management and RTW process^15, including stigma from claims processes, colleagues, professional service providers and employers².

Injured persons who continue engaging in work activities have better outcomes than those off work¹⁴. If someone is off sick for six to 12 months, there is a 90% chance they will not return to work in the foreseeable future; if they are off for more than two years, they are more likely to retire or die than return to work⁴. The experience of the insurance claims process impacts the RTW status and procedural fairness¹⁶; people who were not focused on compensation eligibility¹⁴ resulted in positive RTW outcomes. Supporting claims management through the insurance policy wording and benefits structure in successfully returning employees to work becomes collaborative with role players. The insurer's customer-oriented approach and involving customers actively in the planning and decision-making processes significantly positively affected rehabilitation and allowed the insurer to promote success¹⁷ effectively. The quality and range of resources available to the claims team and services available to assist the claimant also feature as factors that impact DM¹⁰, access to health-focused interventions related to the RTW is seen as an integral RTW intervention¹⁸. Legislation in South Africa supports rehabilitation and return to work following disability⁹. There is, however, a lack of implementation and monitoring of policies that support RTW despite the existence of the policies⁹.

To consolidate an effective disability claims management pathway, we need to understand the factors that impact rehabilitation and work reintegration for injured and ill employees. Dermody and colleagues¹⁹ were confident that the key to improving outcomes in RTW lies in understanding the social and psychological factors that influence disability¹⁹. This speaks to a collaborative approach when integrating social and psychological factors. Employers, employees, and insurers are well-positioned to facilitate reintegration into work environments post-work disability. This article explores the experiences and perspectives of role players within disability claims management, factors that enable or restrict the disability claims management process and identifies the best practice principles required in an insurance disability management pathway during the rehabilitation and work reintegration stages.

 

METHODS

Study design

The methodology for this study referenced the Consolidated Criteria for Reporting Qualitative Studies (COREQ) according to the 32 items on the checklist, which is recommended for comprehensive reporting of qualitative studies²⁰.

Reflexivity and research team

The primary author is a qualified female occupational therapist with ten years' clinical experience spanning private and public healthcare and a further 13 years' experience in corporate insurance, focusing on disability benefits and case management to facilitate RTW. Data collection was completed with the assistance of a co-facilitator. The co-facilitator was a qualified female occupational therapist with four years' clinical experience and corporate insurance experience. The co-facilitator, a disability assessor within an insurance company at the time of the study, was chosen as she had insight into the selection of questions and interview probing due to her familiarity with the study aims, peer debriefing and data triangulation. In a professional capacity, several of the study participants knew the primary author. As a result, the researcher's positionality was made overt through a series of reflective statements and exercises that indicated practical knowledge of the subject of study, allowing for the suspension of judgments as needed and reducing researcher bias. The researcher analysed her goals and how her roles and identities influenced the study techniques.

Study population and sampling strategy

The study focused on a sample of 40 identified stakeholders engaged in the management of private insurance disability claims in South Africa, selected through purposive sampling that aimed for maximum variation. Participants were chosen based on their expertise in ill-health intervention and disability insurance. The first author had professional interactions with several stakeholders. The study purposively sampled its target population from diverse sources such as companies, broker houses, insurance groups, reinsurance groups, and occupational therapy practices. The participants encompassed CM and vocational occupational therapists, Employee Wellness Practitioners (EWP), group insurance disability claims managers, Health Risk Managers (HRM), Human Resources (HR) professionals, insurance brokers, and an Occupational Medical Practitioner (OMP). Individuals were selected based on their knowledge, interest, and experience in the field. To initiate engagement, an expression of interest e-mail was dispatched to five stakeholders within each group, totalling 40 stakeholders. From these, 26 stakeholders responded, representing various roles, including human resource managers (n=4), employee wellness specialists (n=3), occupational health medical practitioners (n=4), group insurance disability claims brokers (n=3), health risk managers (HRM) (n=3), group insurance disability claims assessors (n=3), vocational/case management occupational therapists (n=3), and group insurance reinsurance disability claims managers (n=3). All respondents were subsequently included in the study for interview purposes.

Data collection

Semi-structured interviews were used in this study as this method facilitated in-depth data collection using open-ended and probing questions^21,22. The development of questions was guided by the literature reviewed and the authors' practical experience of RTW. Each interview was conducted in English with the primary author and a co-facilitator to gather the relevant data comprehensively. All participants communicated in English within their respective roles. Interviews were completed after receiving informed consent from the participant. Twenty-six, 60-minute semi-structured interviews were conducted. The interviews were conducted individually to allow the participants to express their personal experiences without influencing other role players.

The interviews occurred online and were audio-recorded and transcribed verbatim using the Microsoft Teams platform. The researcher then checked the relevant transcripts against the audio recordings multiple times to ensure the integrity and amended any incongruences in the data during analysis, thereby providing a basis for trustworthiness²³.

Data analysis and rigour

The data were analysed using thematic analysis, which entailed reading and re-reading the transcripts to identify themes within the data²⁴. Subcategories were created and coded data were placed into each subcategory before formulating categories. The various categories were classified in MS Excel and then grouped into themes and concepts. Via inductive reasoning and analysis, overarching themes that captured the rehabilitation and RTW reintegration phenomenon described by the participants in the study were developed. Trustworthiness of the data centred around confirming credibility, dependability, transferability, and confirmability²⁵. Credibility and member-checking were ensured by reviewing understanding with the participants through paraphrasing and summarising responses in the interview. The interviews were audio-recorded and transcribed to provide accurate data capture. Dependability was facilitated by using the same interview schedule for all participants with additional probing questions to foster a deeper discussion. Confirmability was ensured through reflexivity by noting preconceptions and biases in a notebook and by constantly reflecting on these during the study together with the supervision team. Transferability was confirmed by using detailed descriptions of the research methods, context where possible, maintaining confidentiality, and participants' actual experiences.

Ethical Considerations

Ethics approval was provided by the Human and Social Sciences Ethics Research Committee (HSSREC/00002870/2021) of the University of KwaZulu Natal. The participants were contacted via e-mail to explain the study's aim, purpose, and process. The details about the study, the biographical details request, and consent were sent via e-mail for acknowledgement and signature. The right to withdraw from the research process at any point, research content, and anonymity of data were iterated in the consent and at the start of the interview. All participants provided written consent to participation and publication of data in the study. Confidentiality was maintained by de-identification of participants and the pooling and synthesis of the data sets.

 

RESULTS

Twenty-six individuals volunteered to participate in the study; and included CM/vocational occupational therapists (n=3), EWP (n=3), group insurance disability manager (n=6), HRM (n=3), HR (n=4), OMP (n=4), insurance disability claims broker (n=3). A total of 46% of the stakeholders held an Occupational Therapy qualification, albeit performing different roles in the disability claims management process. All participants who met the inclusion criteria were included in the study. Stakeholders without exposure to disability in the workplace and disability benefits were excluded from the study (Table I below).

 

 

Three themes emerged from the data analysis and reflect the study's aims.

Theme 1: Role Players and their Functions in DCM-Rehabilitation and RTW (Tables II-VI)

This theme identified the role players in the DCM pathway and described their function in the rehabilitation and RTW stage. Five role-player categories were consolidated: (1) employee and employee support structures, (2) employer, (3) intermediary group, (4) medical and rehabilitation, and (5) insurer group. The following tables These are illustrated in tables with verbatim quotes highlighting the participants' voices.

 

 

 

 

 

 

 

 

 

 

The feedback, level of intervention from the medical providers and how the medical condition is explained impact RTW. The medical team is described in Table V (below).

Theme 2: Factors that facilitate and restrict rehabilitation and RTW based on the opinions of the participant group

Several factors posed as facilitators and or barriers to rehabilitation and RTW implementation. The factors listed in Table VII (page 59) have been grouped into the following categories: Laws and Legislation, Employer Incapacity and DM policy/Process, Disability Insurance Products, Insurer mandates, policies and processes, Organisational Culture and mindset, Health Resources, Financial position of the employee and Education training.

Theme 3 - Best Practice Principles

Figure 1 (below) illustrates the five best practice principles that emerged from the study

 

Figure 1 - Click to enlarge

 

Principle 1: Application of Behavioural Economics

Behavioural economics is a field of study that combines insights from psychology and economics to understand how individuals make economic decisions. It examines the psychological factors, cognitive biases, and social influences that impact people's choices in economic situations²⁹

The approach and resultant behaviour of how role players approach disability claims management and manage RTW must be structured to adopt the approach/ attitude that the employee's RTW is integral in promoting quality of life and claims management. Recommendations around access to healthcare must be intentional, realistic, and aligned to the collaborative goals of all role players to support claims management and RTW. Adopting a claims management "philosophy" was recommended.

"Eat, live, breathe claims management because, client management for me is everything we, we can't put things into little pockets. We need to have a very clearly defined philosophy. If you don't have that, it's not going to work,"

Participant 20, Disability Manager

"As a collective if we are focused on the patient, and I think ideally the patient should be at the centre of care if we can truly do that, we will naturally evolve towards a much better space. We talk about it, but the degree to which we actually do it, I think still has a long way to go," Participant 7, OMP.

Principle 2: Governance

The governance framework needs to exist to ensure that the correct policies are in place, so the proper procedures can be followed. These frameworks are fundamental for fairness in the process for all stakeholders.

The following governance frameworks were noted from the respondents:

• Insurance policies must support rehabilitation and RTW through policy wording and benefits, including the employee's role and responsibility in disability claims management. This was highlighted as follows:

"Insurers involvement in rehabilitation can facilitate an early RTW post injury/illness and decrease disability if the financial support and guidance is part of the insurance policy", Participant 18, Claims Manager

• Employer Incapacity and Disability policies should focus on keeping people employed and productive in the presence of medical conditions and applying reasonable accommodations where necessary. The policies should define the processes to be followed in case of loss of productivity due to medical reasons, and stakeholders should be consulted. The policy must outline the workplace environment and people support required to guide and support employees through rehabilitation and RTW. If employees can remain at work while on a partial or fully insured benefit should be considered in the workplace to keep an employee semi or fully engaged in aspects of work function.

Family support greatly influences whether individuals return to work (RTW) after rehabilitation", Participant 18, Claims Manager

"Allowing the employer to remove the employee from payroll reduces the chances of them returning to work. We should push for ongoing payment during this period. If the employer continues to handle the employee's salary, they might be motivated to help them return to work. However, if the employer stops managing the salary and removes the employee from payroll, it damages the relationship between the employer and the employee, discouraging the employer from making efforts to bring them back to work",

Participant 4, Broker

Stakeholder contracts are crucial to clarify roles, comply with requirements, and acknowledgement of roles in the rehabilitation and RTW process. Contracts must ensure that the appropriately qualified stakeholders are sourced to achieve RTW success. Informal contracting with family employees and support structures are also included in this principle. Participant 5, Broker, noted:

"Contracting the right skill for the role and contracting the responsibilities or all parties involved is crucial for accountability and positive outcomes"

Principle 3: Role Player Engagement

The purpose of the key role players identified in Theme One, including the employee, must be maintained throughout the process. The motivation and incentive of the employee to participate meaningfully in treatment and RTW integration must be monitored. Direct contact or communication between the employees and the identified role players is required for successful outcomes.

"Direct contact with employees either in person or telephonically. Are you seeing this person picking up the phone and calling them and saying this is who I am? This is what I'm asking you? Do you have a minute?" Participant 19, Disability manager.

"Having a well-coordinated team is the best way to manage RTW. That has been the biggest differentiator in terms of how well people RTW, or whether they even stay within the workplace" Participant 21, Disability manager

Rehabilitation and RTW planning must be consolidated with all the relevant role players. The plan must ensure that there is understanding, transparency and communication. Feedback loops must be established to adjust plans to achieve the return-to-work goals.

Engagement between stakeholders must allow for a level of flexibility and agility. This includes both proactive and reactive management from the insurer. The insurers' contribution to early identification and management of claims, including financial support for rehabilitation, must be discussed as part of the engagement. Role players engage in the workplace, family environment and medical treatment. Role players must engage with the various treatment pathways for a positive outcome.

"Make sure all parties are talking to each other "

Participant 13, HRM

Principle 4: Resource Identification and Competency

We have outlined the role players that play a critical role in positive RTW outcomes. However, the competency of these role players plays a crucial role in the DCM process and RTW.

• Human Resources

"I think that we need to upskill our managers and our HR in terms of how we integrate and what can be done in the integration period because I think sometimes our managers and our HRBP's are not patient and understanding enough",

Participant 24, HR

• Disability Assessors: There is a focus on RTW because of employing occupational therapists as claims assessors in insurance. The South African occupational therapists working at the insurance companies bring that skill level. Medical background knowledge is integral in claims assessment and is challenging to teach when compared to technical terms and policy conditions and how they are applied

"Understanding medical knowledge and how it relates to function is essential - occupational therapists are probably the best equipped", Participant 21, Disability Manager.

CM Resources in the insurance context must include suitably qualified case managers.

"Case managers with exposure in the corporate and clinical settings have better RTW outcomes based on their practical knowledge in the workplace and exposure to work environments", Participant 20,

Disability Manager

• Environmental Resources should be focused on creating a conducive RTW environment; this is achieved by addressing any previous frustrations between colleagues and educating the employer on stigma and what to expect from the employee upon RTW.

"Ensure that the employee has the tools and, workspace, and access rights that are necessary when they RTW "

Participant 13, H RM

Principle 5: Education and Awareness

• "Ensuring adequate education and awareness is the responsibility of all role players", participant 1 EWP. Medical role players must ensure that the employee understands his medical condition and what interventions are required for RTW.

"The employer has a role in raising awareness of RTW options with colleagues and line managers and workplace sensitisation participant "Participant 16, EWP

• All role players need to understand the product details, the definition of disability, the purpose of the benefit, and how the policy/ product is practically applied at the claim stage. Increased understanding of active participation by employees must occur while they receive disability payment to facilitate RTW. Employees and line managers must understand and be orientated to these key facts from when the product is sold.

"All role players must be educated on the disability benefit when a claim is admitted, including the potential for RTW and termination options for the benefit" Participant 9, Case Manager

 

DISCUSSION

This study confirmed that an integrated stakeholder approach is required to succeed with rehabilitation and work reintegration goals. NIDMAR⁷ supports the need for a multidisciplinary team approach that includes employers, employee's representatives, and disability management rehabilitation service providers, which are essential. Dunstan & MacEachen³ further add the private insurer as part of the team. This study's findings highlight that players' individual and collaborative functions are integral in determining and facilitating RTW success. This is congruent with the literature highlighting the importance of co-operation between stakeholders^3,26. This study found that co-operation must include transparent communication on intervention, prognosis, and alignment of rehabilitation and RTW goals. Streamlining and co-ordinating the functions of each role player is crucial, with active involvement of the employee in goal setting for the return-to-work process. This is essential to prevent fragmented rehabilitation and RTW efforts. The competence of each role player holds significance, and regular monitoring of the RTW plan and the functions of all involved parties must be conducted at agreed-upon intervals.

Ensuring accurate assessments and anticipated outcomes from medical and rehabilitation providers is essential to manage expectations right from the outset of the process effectively. The employee is the key stakeholder who strongly influences RTW outcomes depending on their, level of motivation to engage in the interventions to RTW. The employee's motivation is influenced by various factors, including the work environment, relationship with the employer (including managers and colleagues), family support, cultural beliefs and whether the employee is resilient or not²⁷. Throughout the study, the role of the occupational therapist and insurer was evidenced in the work, health, and insurance systems. The importance of including rehabilitation has been cited previously¹⁰. South Africa's utilisation of rehabilitation services to manage disability claims was limited compared to Australia, North America, and the UK. Evidence indicates that rehabilitation, specifically CM services promote quality and cost-effective RTW outcomes¹¹. The study participants' stance was that rehabilitation, specifically CM by occupational therapists, was necessary for successful and durable RTW reintegration. However, the training and competency of the case manager were highlighted as a strong determinant in measuring success. Case managers who lacked balance between clinical and insurance exposure, insurance policy understanding, and work reintegration processes experienced limited success in RTW reintegration.

One of the participants' significant reasons for limited success is the lack of general training in South Africa. A study concluded in 2018 noted that training in CM at undergraduate and postgraduate levels of occupational therapy is required¹¹. The role of the insurer and occupational therapist is merged in RTW as insurers employ occupational therapists as claims assessors. The participants expressed value in claims assessors being qualified occupational therapists. It provided insight at the claims assessment stage to evaluate the interventions required to consider RTW reintegration and prognosis. Wells and Barrett affirmed that occupational therapists conducted robust assessments confirming occupational impact following injury and illness, and employing occupational therapists in insurance is becoming common to employ occupational therapists in insurance¹⁰. Insurers within the Group Risk Insurance space sit squarely in supporting employers while managing their disability claims experience and supporting employees to achieve a maximal level of function that can result in RTW. This concept was voiced by participants who indicated that the insurer is well positioned to finance RTW rehabilitation, define claims process flows that encourage RTW, facilitate engagement with employers, and provide benefit structures that enable RTW.

Knauf & Schultz²⁸ describe the RTW process as biopsychosocial, this is affirmed by Dermody and colleagues²⁰ in their statement that we need to understand the social and psychological factors that play a role in rehabilitation and work reintegration, in addition to the role players identified. Disability legislation from a South African context of support for rehabilitation is well documented, as vocalised by participants. Still, the application of legislation to facilitate RTW is lacking. This sentiment is echoed in the study by Govender and colleagues⁹ in the local context. Disability legislation is both a facilitator and an inhibitor, depending on whether legislation is enforced in the RTW process. There was consensus amongst participants that a well-defined, transparent employer incapacity and DM policy/process documenting the process and protocols to be followed in the event of injury or illness that leads to work disability is valuable in promoting work reintegration or allowing for a period of work accommodations. The inclusion of a disability management policy demonstrates value for employee retention⁴. Employers' policies that dictate cauterisation of the employee/employer relationship or delayed RTW has been shown to restrict work reintegration. Trippolini and colleagues confirmed that ongoing engagement in work and returning to work as soon as possible⁸ improved RTW outcomes. In addition, unclear insurers' claim processes can lead to client, broker, employer, and employee frustration, thus reducing the RTW collaboration opportunity. Outcomes of claims assessments and utilisation of case managers who are not well-versed in RTW CM negatively influence RTW. The insurer needs to engage resources with the correct expertise to manage claims and optimise CM. Ensuring the accurate identification of employees who will benefit from CM is relevant to the RTW outcomes. Sheehan, Tyler, Gray, Grant, & Collie¹⁶ expressed that procedural fairness by insurers and positive claims experiences contributed to favourable engagement on RTW initiatives. Insurers adopting a customer-orientated approach where the customer is included throughout the process positively impacted rehabilitation¹⁷.

The financial support for rehabilitation in insurance products promotes rehabilitation. However, participants expressed that the insurer restricts access to disability products as goals to RTW may not be well understood or agreed on. The disability-waiting period in insurance policy dictates that disability must be evident for a specific period prior to an employee accessing the disability product. The nature of the waiting period could be seen as restricting early intervention and delaying treatment that could result in RTW. Wells & Barrett¹⁰ identified a limited utilisation of rehabilitation services amongst South African insurers, exposing the opportunity to improve RTW from an insurance perspective. The disability process application and retention of benefits can further ingrain a disability attitude versus a RTW attitude. The role of the disability policy in promoting RTW needs to be positioned firmly through the policy wording and assessment process.

Zooming out of the governance concept and into the environmental space of the employee, the organisational mindset can either promote or restrict RTW reintegration. Participants perceived a general lack of trust in the South African context around medical diagnoses, influencing disclosure by employees due to the stigma related to diagnoses. Organisations that foster stigmatism and reduced disability tolerance tend to restrict RTW. In contrast, organisations where RTW is embedded in the employer's philosophy and disability processes and is well understood, will support RTW. The support provided by line managers and colleagues and their awareness and understanding of the RTW process can either enhance the RTW environment or place stress and anxiety on all role players. Participants agreed that the employee /claimant is the centre of care, and the organisation will naturally evolve to a better RTW space as a collective. This concept is echoed by Dekkers-Sánchez³⁰ conclusion that to address work disability by combining various interventions, considering the holistic well-being of the worker, involving the worker actively, and recognising the significance of the work environment, is believed to be the most effective way to deal with the multifaceted nature of work disability and enhance return-to-work outcomes.

Financial and environmental access to medical treatment, adherence to treatment, and access to skilled specialists positively influence rehabilitation and RTW. The lack thereof is the opposite of not getting a confirmed diagnosis and adequate treatment. The delay in treatment has a dual impact on RTW; the delay in medical treatment complicates recovery and delays the assessment for potential benefits and interventions that could result in RTW. The state of finances of the employee either encourages or restricts RTW depending on the life roles being assumed by the employee.

Participants divulged that some employees would continue to work amidst symptoms and to the detriment of their health due to not getting time off work for treatment or for fear of being placed on disability. When this individual may not work further, rehabilitation and RTW may not be an option, as a WD may appear permanent. There are also instances where employees are driven to RTW post injury and illness, as maintaining their worker role is the only option.

Education and training of all role players is seen as a decisive factor in determining RTW. In circumstances where all stakeholders are well informed on employer processes, insurer processes, reasons for claims decisions and CM, thorough and informed decisions lead to the correct employees engaging in RTW and reintegration with more significant positive RTW outcomes. Awareness and knowledge are crucial to ensuring engagement in the RTW process. Coupled with this are the education and training qualifications of the injured or ill employee. Where opportunities are limited due to educational level and experience, the need for RTW to work may be more significant, and the opportunity to cross-skill the same employee to RTW may be reduced.

Best practice principles have emerged from the findings (as illustrated in Theme 3). Figure 2 (below) summarises how these best practice principles may work from a behavioural economics perspective.

 

 

The concept that role-players need an integrated approach in the environmental and health context is integraI for successful RTW and illuminates the principle of resource identification and competency. The collaboration of these stakeholders in drafting and planning a RTW strategy, facilitating a RTW environment, and contributing to encouraging RTW speaks to a principle of role player engagement. Ensuring sufficient knowledge is disseminated, RTW policies, health conditions, insurance processes, and policies highlight the principle of education and awareness. Ensuring alignment to South African legislation, employer DM policies and insurance policies to promote RTW brings in the principle of governance. All these principles stem from the core concept of the employee being the focus in DCM's rehabilitation and RTW phases. Implementing a biopsychosocial approach and behavioural economics to ensure that all factors are considered around facilitating RTW post-work disability are highlighted as the study's fundamental principle.

 

CONCLUSION

The study has cemented that a collaborative and integrated approach by role-players within an employee's family unit, health system, employer structure and insurance compensation is required for positive RTW to work outcomes. The various role players are responsible for creating policies, structures, intervention strategies, and environments that foster RTW.

The profound impact of rapidly escalating workers' claims costs will be experienced worldwide by businesses and industries throughout the next decade because of reduced strained economies, reduced healthcare options and insurance benefits that provide a source of income. As this crisis challenges the insurance industry, RTW interventions create an opportunity. South Africa is faring well in having conversations around illness and injury and RTW, and employees can access care from an insurer perspective where RTW is possible. A more integrated approach could augment RTW options and give more structure and governance within the DM process to enhance RTW post-injury and illness.

Declaration of conflict of interest

The authors declare no conflict of interest

Author contributions

Dineshree Reddy completed this study towards a Masters in Occupational Therapy degree and was responsible for the conceptualisation of the study, data collection, analysis and drafting of the original manuscript. Pragashnie Govender and Deshini Naidoo were supervisors of the study and guided the process from conceptualisation and design of the study to drafting and revision of the manuscript. All authors read and approved the final manuscript.

 

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Correspondence:
Pragashnie Govender
Email: naidoopg@ukzn.ac.za

Submitted: 3 September 2023
Reviewed: 30 November 2023
Revised: 21 January 2024
Accepted: 21 January 2024

 

 

Editor: Hester M. van Biljon: https://orcid.org/0000-0003-4433-6457
Data availability: All transcripts and raw data are available upon reasonable requests from the corresponding author.
Funding: The University of KwaZulu-Natal is acknowledged for tuition remission for the first author towards a Master's Degree, from which this paper emanates.