Making a claim
A copy of the workers compensation medical certificate should be given to the employer who must, within 3 days pass it on to their workers compensation insurer, along with paperwork concerning lodgement of the new claim. From the information provided the insurer assesses the liability status and whether they will support treatment. Some treatments such as physiotherapy and the initial visit to the NTD do not need the approval of the insurer; however ongoing treatment and expenses must be approved except in limited number of specific circumstances.
There are 3 types of claim status in NSW for example, that can occur following claims lodgement and they include:
Full liability - relatively rare when the insurer fully accepts liability for what has happened - most likely after a significant injury that was associated with an investigation by WorkCover
Provisional Liability - liability is accepted for treatment and payment of wages, and treatment for a period of time until the claim and circumstances are fully investigated. The claim may later be accepted in full or declined.
Reasonable Excuse
There are some circumstances where the costs of treatment and wages are not required to be paid because of “a reasonable excuse”. Some examples of this may be a psychological injury claim where performance management issues over alleged poor performance or misconduct have been carried out by the employer and the employee has become distressed and reported a psychological injury. Even though wages and treatments are not paid, the insurer is required to have the claim investigated and the workers medically or psychiatrically assessed independently After all the evidence is collected and reviewed a decision is made about the future claim status as to whether the claim is accepted or declined.
The role of the insurer / agent
The insurers, now called “agents” by WorkCover NSW play key roles in the management of the Workers compensation system. They hold the purse strings to medical and paramedical assessments and treatments, to rehabilitation access and the ability of the worker to access a weekly wage when they are injured. Over the last 5 or so years agents have been given increasing freedom in the way they manage claims to fit within their approved WorkCover business model, providing they adhere to the legislation and WorkCover Guidelines concerning procedures, practices and timeframes. Since the O’Farrell Government’s 2012 legislation was passed their power has increased further in that the assessments they undertake on injured workers, particularly work capacity assessments are harder to challenge successfully as many of the appeal mechanisms have been watered down.
Some of the roles of the agents / insurers are summarised below:
- Collect premiums from employers for their compulsory WorkCover policies
- Calculate and adjust premiums according to industry, occupation, and claims history
- Organise relevant assessments to determine liability
- Provided timely information to stakeholders over issues of liability and treatment changes
- Develop a coordinated injury management plan with responsibilities outlined for treatment providers and other stakeholders
- Pay for “reasonably necessary” medical assessments and treatments
- Monitor the effectiveness of treatments - through discussion with service providers and the organisation of“independent” assessments
- Pay the injured worker a wage according to relevant legislation and make adjustments as require by legislation to accommodate changed or specific circumstances
- Monitor compliance e of workers to their “obligations”in attending specialist appointments, treatments, job searching.
Contacts with the Agent
As an employer you are required to lodge a claim with the agent that holds your policy within 3 working days of it being reported by the injured worker. Within a week of lodging the claim with you, your injured worker should receive correspondence from the agent. The case manger assigned to their claim may call them, or you to discuss the claim or some issue related to treatment. A claim number should also be assigned within this time frame.
It is important to understand that being assigned a claim number does not mean that the injured worker’s claim has been accepted. It merely means a claim has been registered and a decision is to be made about status. You can refer to the preceding sections on different type of claims status. In the letter the worker receives from the agent giving them claim number, the letter may outline a management plan and some information about their responsibilities. A copy of the initial and follow up management plan is also sent to other stakeholders such as treating professionals, the employer, insure outlining goals and responsibilities.
In the first month after injury it is likely the injured worker will receive correspondence from the agent on several occasions so they are notified of claim number, the claim status and be provided with an initial injury management plan if required. The case manger may call the injured worker or you to advice on a matter related to a treatment request, or payment of wages.
The approach and professionalism of “case managers” various greatly from agent to agent and between agents. Some case managers are informative, polite, helpful and empathetic. Others may be ignorant, lacking knowledge and experience, prone to rudeness, or are, suspicious and generally unhelpful. This will be discussed at some length in the section “Challenges in the Workers Compensation system”.
What you, as the employer should be doing
In the first month post injury you should:
- Make sure the injured worker has detailed the incident leading to the workers compensation claim
- Complete and lodge the paperwork related to your claim
- Forward payment for wages passed on from the insurer to the worker immediately after they receive them
- Offer suitable duties as per guidelines on the medial certificate
- If you have difficulties providing suitable duties, or is unsure what you should be doing you should contact the insurer or WorkCover for advice.
What your worker needs to be doing - their obligations
To receive and continue to receive workers compensation benefits and have their treatment and rehabilitation expenses paid for, injured workers need to:
- Attend appointments with their NTD as requested
- Ensure their medical certificate is always up to date and forwarded to relevant parties - particularly the agent who is paying you
- Attend all referrals made by their NTD for assessments and treatment
- Give adequate notification of cancellation if they are unable to attend.
- Advise their doctor or the agent of any change in circumstance - i.e. injury status, change of address
- Undertake medical assessments organised by the agent providing they are given reasonable notice and they are within a distance that the worker is able to travel in context of their injury
- Participate in rehabilitation programs organised by the agent or you as their employer ( although they can elect to change provider if they are not happy with the service of the employer or agent appointment provider)
The role of WorkCover in the first month
If all parties do what they are supposed to do in the first month there shouldn’t be need for WorkCover assistance. If there are problems in the following areas a call to their assistance line may be warranted and help up in getting things moving forward with the claim. Situations where WorkCover may become involved i9n the first month include:
- You as the employer won’t lodge a claim
- You as the employer don’t appear to have a policy
- The worker’s injury was caused by a clear and significant occupational Health and safety breach
- There is no response from the agent about the claim within 10 days
- Your worker is not advised of your claim status and you receive no wage payment after 2 weeks
- Treatment or investigations that the injured worker’s doctor recommends as reasonably necessary are ignored or refused
- You’re as the employer refuse to offer suitable duties consistent with the workers medical certificate.
SOME CONSIDERATIONS IN THE FIRST MONTH OF A CLAIM FOR EMPLOYERS
- Learn about the injury your worker has- what is injured, why, could it have be prevented, consider ways to minimise it injury happening again
- Consider What the effect of injury may be on the injured worker, team leader, and other staffas well as the organisation overall and respond to particular issues
- Learn What is a Workers Compensation Medical Workcover certificate is, what it means and your responsibilites
- Learn about and understand what “suitable duties” mean - your obligations and what you need to consider
- Create an environment for making the worker want to come back – Support your injured worker, educate staff, provide suitable duties,
