Standards of practice

Commencement date: 4 April 2022

About the standards

SIRA uses the Standards and Guidelines to hold insurers accountable for the delivery of a high standard of service to workers and their families, carers, employers and other system stakeholders.

Context

A principal objective of SIRA in exercising its functions is to provide for the effective supervision of claims handling and disputes arising under NSW workers compensation legislation, in accordance with section 23 of the State Insurance and Care Governance Act 2015.

The Standards of practice: Expectations for insurer claims administration and conduct (Standards) together with the Workers compensation guidelines (Guidelines) set clear, consistent, accessible and enforceable expectations that will guide insurer conduct and claims management.

The Standards and Guidelines are part of SIRA's regulatory framework, which also includes the:

Workers Compensation Act 1987 (the 1987 Act)
Workplace Injury Management and Workers Compensation Act 1998 (the 1998 Act)
Workers Compensation Regulation 2016 (2016 Regulation).

Purpose

The Standards support and encourage insurers to have effective claims management practices to help deliver positive experiences and outcomes for workers, employers and the people of NSW.

The Standards contain overarching claims management principles. These principles apply generally and guide all claims management activity to meet the system objectives outlined in section 3 of the 1998 Act. The principles articulate a strategy built on:

fairness and empathy
transparency and participation
timeliness and efficiency.

The Standards require insurers to apply principles across a range of processes and procedures in claims handling and administration. The principles and expectations target activities where it is known that insurer processes or procedures have impacted the worker's claims experience. They seek to provide clarity where confusion or inconsistency among insurers has led to inequitable compensation outcomes for workers and employers.

The Standards are designed to be flexible and responsive to the changing regulatory landscape. New Standards have been developed in response to new or emerging issues, including new Standards for managing claims during the COVID-19 pandemic and managing psychological injury claims.

Standard 32: Managing claims during the COVID-19 pandemic

In June 2020, a new Standard of practice was developed to set expectations for insurers about the handling of COVID-19 workers compensation claims and claims handling practices more generally throughout the period of the pandemic. Specifically, Standard 32 was designed to:

clarify expectations regarding insurer decision making and determination of weekly payment entitlements to promote transparency and consistency, and provide certainty for impacted workers
reduce barriers and ensure workers are fully informed of supports and options available to them
support workers through their recovery and return to work.

The Standard also supports the presumptive provisions introduced in May 2020 to enable workers in prescribed employment who are diagnosed with COVID-19 to automatically be presumed to have contracted the disease in the course of their employment.

SIRA will continue to closely monitor the management of COVID-19 related claims and will consult on the need to further refine this Standard if appropriate.

New Standard 33: Managing psychological injury claims

A new Standard of practice has been developed to support and set expectations for insurers in their management of claims for workers with a psychological injury. Standard 33 is designed to:

promote the management of claims in accordance with legislative requirements, while tailoring services to workers’ needs, providing transparent communication about the process, establishing trust with the worker and focusing on early treatment and return to work
support the insurer to adopt practices across four key evidence-based domains including:
- person-centred approach
- collaboration
- early identification of support needs
- outcome focused decision-making.

These themes are supported by the Safe work Australia publication Taking Action: A best practice framework for the management of psychological claims in the Australian workers’ compensation sector (The Taking Action Framework). This approach has previously been endorsed by SIRA and has the broad support of workers compensation schemes across Australia.

Standard 33 also provides guidance to assist insurers to identify claims with an elevated risk of a secondary psychological injury. Secondary psychological injury usually results from the psychological impact of a physical injury, and the impacts of secondary psychological injury need to be considered to support individuals in their recovery and returning to work.

Application

The Standards within this document form the claims administration manual, for the purposes of section 192A of the 1987 Act.

All insurers are expected to comply with these Standards, except for Coal Mines Insurance Pty Ltd and icare Dust Diseases Care. However, SIRA encourages all insurers operating in the NSW workers compensation system to adopt the overarching claims management principles and any relevant Standard.

Exempt categories of workers (‘exempt worker’)

The term ‘exempt worker’ refers to specific classes of workers for which most of the amendments made to the Workers Compensation Acts in 2012 and 2015 do not apply. These classes of workers include police officers; paramedics; fire fighters; rescue workers; and bushfire, emergency and rescue service volunteers.

The Standards apply to exempt categories of workers unless otherwise indicated in the standard.

Scope

The Standards contain overarching claims management principles that are intended to apply generally to all claims handling and administration activities. They clearly state the outcomes insurers are to achieve in the administration of claims.

Individual Standards apply to particular claims management topics, and are presented in a way to make clear the following elements:

Principle: the broad principle to be adopted by insurers when dealing with a particular aspect of a claim.
Expectations: SIRA expectations for processes, procedures or methods to be applied in the handling and administration of claims relevant to that Standard topic.
Benchmarks: an indication of what claims activities or actions SIRA may use to measure insurer performance against expectations.

The Standards should be read in conjunction with the requirements of the workers compensation legislation, regulation and guidelines.

Additional information to provide context and explain the rationale for each Standard is included in the on-line claims management guide.

Words used in the Standards of Practice have the same meaning as the words contained in the NSW workers compensation legislation.

Commencement

The overarching claims management principles and standard principles apply generally to all claims from 1 January 2019.

Standard 32 Managing claims during the COVID-19 pandemic commenced from 26 June 2020, and will continue to be in effect unless SIRA amends, revokes or replaces the Standards.

Standard 33 Managing psychological injury claims applies for all claims from 1 March 2021.

The principles will continue to apply until SIRA amends, revokes or replaces them in whole or in part.

Directions to comply with these Standards, including the expectations and benchmarks, may be issued to insurers under Division 4 of Part 7 of the 1987 Act, which will make contravention (breach) of a requirement of the Standards an offence under section 209 of the 1987 Act. Section 194(2) makes compliance with a direction to insurers a condition of an insurer's licence issued under the Act.

SIRA may issue a Direction to insurer(s) to comply with individual Standards and/or all of the Standards.