Claims and injury management

Overview

An ‘initial notification of injury’ is the first notice an insurer receives regarding an injury to a worker.

An injury is usually notified to the insurer by the employer but may also be notified by the worker, doctor or other party.

This guidance covers an insurer's obligations following initial notification.

When the initial notification of injury is incomplete

If the insurer receives an incomplete initial notification of injury, they should contact the notifier (and the worker where possible) within three business days and specify what additional information is needed (see Part 1 of the Workers compensation guidelines).

The insurer requires the following information for the initial notification of injury as specified by Part 1 of the Workers compensation guidelines.

When the notified insurer is not the current insurer of the employer

If the insurer cannot find a policy that covers the employer, the insurer should contact the worker and employer (and the notifier, if not the worker or employer) within three business days of receiving a notification of injury, to gather more information to try and identify the policy.

If the insurer still cannot identify the policy, they should:

• tell the worker, employer and notifier (if applicable) that they are not the current insurer
• refer the notifier to the SIRA Customer Service Centre (on 13 10 50) or icare Uninsured Liability Insurance Scheme (on 13 44 22).

Once the current insurer has been identified, the notified insurer should:

• immediately pass the notification on to the current insurer
• advise the worker, employer and notifier of the current insurer’s details by phone, and then follow-up in writing.

Initial contact

If the initial notification is for a significant injury, the insurer must make contact with the worker, the employer (except when the employer is a self-insurer) and (if appropriate and reasonably practicable) the worker’s nominated treating doctor, within three working days, and initiate action under the insurer’s injury management program.

During this contact, the insurer should gather information that will help the insurer make a full or provisional liability decision. It also provides an opportunity to establish the worker’s injury management plan in consultation with the worker, nominated treating doctor and employer. See Standard of practice S34. Return to work – early intervention and S12. Injury management plans.

During the initial contact the insurer should discuss:

• the importance of recovery at work and health benefits of good work
• the worker’s individual situation and circumstance
• tailored expectations about frequency and method of agreed contact
• how risk factors for delayed recovery across the four domains (personal, workplace, insurance and healthcare) will be identified, e.g. risk assessment
• potential suitable employment opportunities
• the injury management plan and the activities to be undertaken as part of this plan
• roles, responsibilities, rights and obligations of each stakeholder.

As this is often the first point of contact between the insurer and the worker, it is important to build rapport and establish transparent and open communication in line with SIRA’s Customer Service Conduct Principles.

Insurers should be aware that for many workers this is their first exposure to the workers compensation system, and they may be feeling confused and overwhelmed.

Insurers should clearly explain the claims and injury management processes and inform the worker what they can expect to happen next.

Insurers should ensure that comprehensive file notes are taken during the initial contact. This will ensure the worker does not have to repeatedly recount the circumstances of their injury, this can be especially harmful for workers with a psychological injury.

Insurer obligations after receiving initial notification of injury

When an initial notification of injury is received, the insurer should first check that sufficient information has been provided to identify the employer’s current policy of insurance.

If the insurer is the current insurer of the employer, then sections 267 and 268 of the Workplace Injury Management and Workers Compensation Act 1998 (1998 Act) provide that within seven days of the initial notification to the insurer of an injury to a worker, the insurer must either:

• commence provisional payments of weekly compensation (for up to 12 weeks), or
• if a reasonable excuse exists for not commencing weekly payments, send the worker a written notice giving details of the reasonable excuse and advising that the worker is entitled to make a claim (and explain how that claim can be made).

A worker will benefit from being informed about how a reasonable excuse may be resolved, whether by the insurer or the worker. Once resolved the insurer can then advise the worker about the resolution and next steps.

An insurer can also determine liability for the claim. (Refer to Chapter 7, Part 3, Division 1 of the 1998 Act and the Workers compensation guidelines).

If a claim is disputed, the insurer and employer continue to have workplace injury management obligations (refer to Section 41A, Chapter 3 of the 1998 Act).

When a claim for weekly payments is the first notification of injury

If a claim for weekly payments is the first notification of injury received by the insurer, they must treat it the same way as any other initial notification of injury - see above.