Part A - How claims process works Flashcards

1
Q

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

A

notify the employer and the insurer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

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

A

written or verbal notification

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

the employer must keep

A

a readily and accessible register of injuries in the workplace

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

when the employers become aware, they must

A

notify their insurer within 48 hours.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

an insurer can also be notified by the

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

notification to the insurer can be by

A

a written form (email) or verbal (phone)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

initial notification

A

notification to the insurer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

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

A

name and contact details

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

the following details are required to notify the insurer: employer

A

business name and contact details

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

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

A

name and name of medical centre or hospital

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

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

A

name, relationship to the worker or employer, contact details

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

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:

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

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

A

three business days and specify the information needed.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

The date the notification is completed becomes the

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

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

A
  1. Start provisional payments (see A2).
  2. Delay starting provisional weekly payments due to a reasonable excuse (see A2).
  3. Determine liability (see Part B or Part C).
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

The insurer may also commence payments for

A

medical expenses on a provisional basis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

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

A

provisional medical
payments

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

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

A

be commenced as soon as possible

24
Q

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

A

determine liability within 21 calendar days

25
Q

Starting provisional payments does not mean

A

the insurer or employer admits liability for the injury

26
Q

starting provisional payments allows the insurer to

A

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

27
Q

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

A

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

28
Q

The worker also has a right to seek an

A

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

29
Q

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

A

direct the provisional payments to commence under an interim payment direction

30
Q

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

A

writing. You should
also inform the employer.

31
Q

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

A

■ 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

32
Q

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

A

■ 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

33
Q

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

A

a claim form and the Information for injured workers brochure.

34
Q

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

A

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

35
Q

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

A

attempt to resolve
the reasonable excuse.

36
Q

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

A

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.

37
Q

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

A

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

38
Q

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

A

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)

39
Q

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

A

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

40
Q

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

A

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

41
Q

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

A

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

42
Q

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

A

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.

43
Q

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:

A

■ 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.

44
Q

How to communicate a reasonable excuse for delaying payments

The notice to the worker must set out:

A

■ 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.

45
Q

How to communicate a reasonable excuse for delaying payments

You should supply a claim form and explain:

A

■ 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

46
Q

Stopping provisional payments

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

A

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

47
Q

Stopping provisional payments

Provisional weekly payments can also be stopped if

A

■ 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.

48
Q

Stopping provisional payments

The insurer can stop provisional medical payments if:

A

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

49
Q

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

A

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

50
Q

A3 Claims for compensation

In making a claim, workers are asserting a right to

A

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

51
Q

Requirement for a claim form

A worker is able to complete and submit a

A

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

52
Q

Requirement for a claim form

A claim form is required if

A

■ 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

53
Q

Requirement for a claim form

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

A

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

54
Q

Requirement for a claim form

The claim must be made within

A

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.

55
Q

Information required to support a claim

As a worker, if you are claiming compensation, you must supply information that shows you

A

■ 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

56
Q

Responding to a claim

The employer must:

A

■ 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