Part A - How claims process works

Question 1

A1 Initial Notification of an Injury -1st step in claiming compensation for work-related injury

Answer 1

notify the employer and the insurer

Question 2

a worker must notify the employer as soon as an injury happens, unless special circumstances apply. A worker can do that by

Answer 2

written or verbal notification

Question 3

the employer must keep

Answer 3

a readily and accessible register of injuries in the workplace

Question 4

when the employers become aware, they must

Answer 4

notify their insurer within 48 hours.

Question 5

an insurer can also be notified by the

Answer 5

worker or the representative of the worker or the employer (ie doctor or union rep)

Question 6

notification to the insurer can be by

Answer 6

a written form (email) or verbal (phone)

Question 7

initial notification

Answer 7

notification to the insurer

Question 8

if the worker or the rep of the worker asks for the insurer’s name, the employer must

Answer 8

provide it to the worker. Otherwise if it cannot be done, the worker can contact SIRA

Question 9

the following details are required to notify the insurer: worker:

Answer 9

name and contact details

Question 10

the following details are required to notify the insurer: employer

Answer 10

business name and contact details

Question 11

the following details are required to notify the insurer: treating doctor (if relevant)

Answer 11

name and name of medical centre or hospital

Question 12

the following details are required to notify the insurer: injury:

Answer 12

date, time, description of injury, and how it was acquired

Question 13

the following details are required to notify the insurer: notifier:

Answer 13

name, relationship to the worker or employer, contact details

Question 14

if insurer cannot find a policy cover within 3 business days of the notification, the insurer should contact the employer: If it cannot identify the policy, the notified insurer should:

Answer 14

■ tell the worker, employer and notifier that it is not the current insurer
■ refer the notification to the SIRA Customer Service Centre.

Question 15

if insurer cannot find a policy cover within 3 business days of the notification, the insurer should contact the employer: If the current insurer can be identified, the notified insurer should

Answer 15

■ pass the notification on to the current insurer immediately
■ advise the worker, employer and notifier in writing

Question 16

If the insurer receives an incomplete notification, it should tell the notifier (and the worker, where
possible) within

Answer 16

three business days and specify the information needed.

Question 17

The date the notification is completed becomes the

Answer 17

‘initial notification date’, which affects provisional
payments (see A2).

Question 18

Once the notification is complete, the insurer must review the information and take one of these
actions:

Answer 18

5. Start provisional payments (see A2).
6. Delay starting provisional weekly payments due to a reasonable excuse (see A2).
7. Determine liability (see Part B or Part C).

Question 19

A2 Provisional payments: The insurer may make provisional payments before it determines liability (see Part B or Part C) to cover:

Answer 19

■ up to 12 weeks of payments for loss of income
■ up to $7,500 for reasonably necessary medical treatment

Question 20

Starting provisional payments: Once the insurer has received an initial notification of an injury, it must

Answer 20

start provisional weekly
payments within seven calendar days unless it has a reasonable excuse not to.

Question 21

The insurer may also commence payments for

Answer 21

medical expenses on a provisional basis.

Question 22

A reasonable excuse may apply to provisional weekly payments, but not to

Answer 22

provisional medical
payments

Question 23

Where provisional medical payments are to be made, these should be

Answer 23

be commenced as soon as possible

Question 24

Where a worker claims medical expenses but these are not paid under provisional payments, the
insurer must

Answer 24

determine liability within 21 calendar days

Question 25

Starting provisional payments does not mean

Answer 25

the insurer or employer admits liability for the injury

Question 26

starting provisional payments allows the insurer to

Answer 26

provide the worker with financial assistance and early intervention while doing investigations to determine liability

Question 27

Where the insurer does not commence provisional payments and/or issue a reasonable excuse, the worker may seek assistance from

Answer 27

■ the insurer ■ SIRA’s Customer Service Centre on 13 10 50 ■ Workers Compensation Independent Review Officer (WIRO)

Question 28

The worker also has a right to seek an

Answer 28

expedited assessment by application to the Registrar of the Workers Compensation Commission

Question 29

The Registrar (or delegate) of the Workers Compensation Commission may

Answer 29

direct the provisional payments to commence under an interim payment direction

Question 30

As an insurer, when starting provisional payments you must notify the worker in

Answer 30

writing. You should also inform the employer.

Question 31

when notifying the worker and the employer to start provisional payments the notice must explain:

Answer 31

■ that the payments have started but are on a provisional basis ■ how long they are expected to last for ■ that an injury management plan will be developed if the worker is unable to return to their pre-injury employment for seven continuous days ■ that the worker can make a claim and how to do so

Question 32

when notifying the worker and the employer to start provisional payments the notice must include:

Answer 32

■ the worker’s pre-injury average weekly earnings ■ the amount of weekly payment and how that amount has been calculated (including a copy of the completed PIAWE form where one has been provided) ■ who will pay the worker (either the employer or the insurer) ■ what to do if the worker disagrees with the amount or does not receive payment ■ what information the worker needs to provide the insurer for weekly payments to continue

Question 33

when notifying the worker and the employer to start provisional payments the notice must also supply:

Answer 33

a claim form and the Information for injured workers brochure.

Question 34

If you include information in starting provisional payments notice which is a work capacity decision, you should ensure that it is communicated to the worker as

Answer 34

prescribed in the ‘Work capacity decision’ chapter (see B1.3)

Question 35

Where applicable, prior to delaying provisional weekly payments, the insurer should

Answer 35

attempt to resolve the reasonable excuse.

Question 36

The insurer has a reasonable excuse for not starting provisional weekly payments if any of the following apply: There is insufficient medical information

Answer 36

The insurer does not have enough medical information to establish that there is an injury, as a Workers compensation certificate of capacity or other medical information certifying that an injury has occurred, has not been provided. Note: Use discretion for workers in remote areas if access to medical treatment is not readily available.

Question 37

The insurer has a reasonable excuse for not starting provisional weekly payments if any of the following apply: The injured person is unlikely to be a worker

Answer 37

The person cannot verify they are a worker or the employer can verify that they are not a worker. If there is any doubt that someone is a worker under the workers compensation law, the insurer must verify that person’s status. Information that confirms this may include but is not limited to: ■ the employer agreeing to the worker’s status ■ the worker’s payroll number ■ a current payslip or a bank statement with regular employer payments ■ a contract of employment or services

Question 38

The insurer has a reasonable excuse for not starting provisional weekly payments if any of the following apply: The insurer is unable to contact the worker

Answer 38

The insurer has not been able to contact the worker after at least: ■ two attempts by phone (made at least a day apart) ■ one attempt in writing (which may include an attempt by email)

Question 39

The insurer has a reasonable excuse for not starting provisional weekly payments if any of the following apply: The worker refuses access to information

Answer 39

The worker will not agree to the release or collection of personal or health information relevant to the injury to help determine their entitlement to compensation

Question 40

The insurer has a reasonable excuse for not starting provisional weekly payments if any of the following apply: The injury is not work related

Answer 40

The insurer has information that: ■ the worker did not receive an injury which is compensable under the NSW workers compensation law, or ■ strongly indicates that compensation for an injury may not be payable under the workers compensation law. If the employer believes the injury is not work related, it should provide to the insurer supporting information, such as: ■ medical information that the condition already existed and has not been aggravated by work ■ factual information that the injury did not arise from or during employment. Note: Suspicion, innuendo, anecdotes or unsupported information from any source, including the employer, is not acceptable

Question 41

The insurer has a reasonable excuse for not starting provisional weekly payments if any of the following apply: There is no requirement for weekly payments

Answer 41

A notification of injury has been received; however the insurer has verbal or written confirmation from the worker and employer that they do not anticipate that weekly payments will be claimed

Question 42

The insurer has a reasonable excuse for not starting provisional weekly payments if any of the following apply: The injury is notified after two months

Answer 42

The notice of injury is not given to the employer within two months of the date of injury. Note: The insurer should disregard this excuse if liability is likely to exist and it believes provisional payments will be an effective way to manage the injury.

Question 43

How to communicate a reasonable excuse for delaying payments As an insurer, if you have a reasonable excuse for not starting provisional weekly payments, you must:

Answer 43

■ must give the worker written notice within seven days of receiving the initial notification ■ should also tell the employer in writing as soon as possible.

Question 44

How to communicate a reasonable excuse for delaying payments The notice to the worker must set out:

Answer 44

■ the excuse(s), and should include copies of all relevant information you considered in the decision ■ that the worker can still make a claim for compensation, which the insurer will determine within 21 days of receipt ■ how the worker can make that claim.

Question 45

How to communicate a reasonable excuse for delaying payments You should supply a claim form and explain:

Answer 45

■ how the excuse can be resolved ■ that the worker can talk to the insurer for further information ■ that the worker can seek help from their union, SIRA’s Customer Service Centre on 13 10 50 or Workers Compensation Independent Review Officer on 13 94 76. ■ that the worker has a right to seek an expedited assessment by application to the Registrar of the Workers Compensation Commission

Question 46

Stopping provisional payments The insurer can stop provisional weekly payments if the worker does not supply, within seven days of receiving a request for:

Answer 46

■ a certificate of capacity, or ■ a signed form of authority to allow the insurer to obtain information about the injury.

Question 47

Stopping provisional payments Provisional weekly payments can also be stopped if

Answer 47

■ the worker returns to work before the provisional payments end and faces no ongoing loss of earnings, or ■ liability for the claim for weekly payments is accepted or disputed.

Question 48

Stopping provisional payments The insurer can stop provisional medical payments if:

Answer 48

■ the worker is not seeking any further medical treatment for the injury, or ■ liability for the medical expenses claim is accepted or disputed.

Question 49

If liability for compensation benefits is disputed while provisional payments are being made, the insurer must

Answer 49

t issue a notice of dispute (see B10 or C4).

Question 50

A3 Claims for compensation In making a claim, workers are asserting a right to

Answer 50

receive workers compensation because they believe they meet the legal requirements for receiving benefits

Question 51

Requirement for a claim form A worker is able to complete and submit a

Answer 51

claim form to the insurer at any time. A claim form is available at www.sira.nsw.gov.au

Question 52

Requirement for a claim form A claim form is required if

Answer 52

■ a reasonable excuse notice has been issued and the excuse continues to exist, or ■ compensation is likely to be claimed beyond provisional payments and the insurer determines that there is insufficient information to determine ongoing liability

Question 53

Requirement for a claim form The insurer can waive the requirement for a worker to submit a claim form, if

Answer 53

they determine they have enough information to make a liability determination.

Question 54

Requirement for a claim form The claim must be made within

Answer 54

six months of a worker’s injury or accident (or within six months of a worker becoming aware of an injury). This time limit may be extended in certain circumstances.

Question 55

Information required to support a claim As a worker, if you are claiming compensation, you must supply information that shows you

Answer 55

■ were employed Sections 4 and 5, and Schedule 1, of the 1998 Act ■ received an injury from or during the employment ■ have lost income, need medical treatment or may incur other expenses because of that injury. You can also provide other information that supports your claim

Question 56

Responding to a claim The employer must:

Answer 56

■ forward any workers compensation claim or information about a claim to the insurer within seven days of receiving it ■ respond to the insurer’s requests for information about a claim within seven days