Claims decisions

A work capacity assessment is an assessment of a worker’s current work capacity. A work capacity assessment can include a review of the worker’s functional, vocational and medical status.

A work capacity assessment helps inform work capacity decisions by insurers. Work capacity decisions include (but are not limited to) decisions about the worker’s current work capacity, what may be suitable employment for a worker, what a worker may earn in suitable employment, and ability to return to their pre-injury employment or other suitable employment.

Work capacity decisions are important as they help the insurer accurately determine the amount of the weekly payment of compensation a worker is able to be paid (see ‘Work capacity decisions’).

Assessing work capacity

Work capacity assessments are conducted throughout the life of a claim whenever new information about the worker’s capacity (such as a certificate of capacity) is received which may affect a worker’s weekly payments. This is part of normal claims management.

The ongoing review and assessment of a worker’s work capacity may involve the consideration of a range of information, including:

• certificates of capacity (see 'Certificate of capacity')
• reports and notes from the worker’s nominated treating doctor and specialists
• treating practitioner reports
• workplace rehabilitation provider reports
• independent and medical assessment reports
• vocational assessment reports
• functional assessment reports
• evidence of pre-injury or current wages
• communication with the worker.

A work capacity assessment may be based on available information (for example, a certificate of capacity), or it can mean the insurer needs to gather additional information. The insurer may need to source functional or vocational assessments in order to get all the information they require.

The insurer may require the worker to attend an appointment (usually with a medical or health care provider) in order to obtain more information about the worker’s capacity for work.

When will a work capacity assessment be conducted

In addition to reviewing work capacity whenever new information about the worker’s capacity is received, insurers must also conduct a work capacity assessment after the worker has received weekly payments for an aggregate of 78 weeks, where it is likely that the worker’s entitlement to weekly payments will continue beyond 130 weeks. The assessment must be completed before the worker has received an aggregate of 130 weeks of weekly payments.

After 130 weeks of weekly payments, the insurer is expected to assess the worker’s work capacity at least once every two years.

Requirement to attend an appointment

If the insurer requires the worker to attend an appointment in order to assess their work capacity, the insurer is to advise the worker of the date and time of each appointment at least 10 working days before the appointment, unless otherwise agreed by the worker.

The advice must include:

• the location of the appointment
• the purpose of the appointment and how it may inform the work capacity assessment
• the information that refusing to attend, or failing to properly participate (so that the assessment cannot take place), may result in the insurer suspending weekly payments until the assessment appointment is completed.

The Workers compensation guidelines (the Guidelines) outlines the requirements for attending appointments. Part 5 of the Guidelines provide that a worker cannot be required by the insurer to attend more than four appointments per work capacity assessment. Of these, there cannot be more than:

• one appointment with the same type of medical specialist (for example, orthopaedic surgeon, psychiatrist)
• one appointment with the same type of healthcare professional (for example, physiotherapist, psychologist).

Part 5 of the Guidelines also require insurers to consider whether the requirement to attend an appointment is reasonable. The worker should discuss any concerns about attending an appointment with their insurer, or the worker may seek the assistance of the Independent Review Office (IRO) on 13 94 76.

If the worker is required to attend an independent medical examination, this must be in accordance with Part 7 of the Guidelines.

Assessing the worker's ability to return to pre-injury employment

When assessing the worker’s ability to return to their pre-injury employment, the insurer assesses the worker’s functional capacity against the nature, duties, tasks, and hours of work of their pre-injury employment.

To measure the worker’s functional capacity, the insurer assesses and weighs the available medical and functional information. This may include:

• certificates of capacity
• reports and notations from the worker’s nominated treating doctor and specialists
• independent medical examination and injury management consultant reports
• functional assessment reports.

An insurer assesses information currency according to the circumstances of each claim.

There may be situations involving old injuries where there are no recent certificates of capacity or reports. In these cases, the most recent available information is used.

If the insurer determines that the worker cannot return to their pre-injury employment, then it must decide if the worker can instead work in other suitable employment (see 'Assessing suitable employment' below).

Assessing the worker's capacity to return to work in suitable employment

If the worker has a capacity to return to suitable employment, the insurer must identify the type(s) of employment the worker is currently suited to. This involves assessing the worker’s functional and/or vocational capacity.

The insurer should consider all of the available information in assessing the worker’s capacity to work in suitable employment.

Assessing suitable employment

The insurer assesses suitable employment using all the available information and applying the definition outlined in section 32A of the Workers Compensation Act 1987 (1987 Act).

Suitable employment is work for which the worker is currently suited, having regard to:

• the nature of the worker’s incapacity
• the worker’s age, education, skills and work experience
• any plan or document prepared as part of the return to work planning process
• any occupational rehabilitation services that are being, or have been, provided to/for the worker.

An assessment of the worker’s ability to perform suitable employment does not take into consideration:

• whether the work or the employment is available
• whether the work or the employment is of a type or nature generally available in the employment market
• the nature of the worker’s pre-injury employment, or
• the worker’s place of residence.

Worker age, education, skills and work experience

The worker’s age, education, skills and work experience are considered when assessing suitable employment options. The insurer considers whether the suitable employment option requires a form of qualification such as a degree or certification.

The insurer also considers whether the worker has the necessary skills and experience to be competitive in the open labour market.

Work trials

Insurers may look at the outcome of any work trials (see ‘SIRA funded programs’) the worker has completed to determine whether they have the practical experience required for the suitable employment option.

Work trials alone cannot determine the suitability of employment options. The insurer will assess suitable employment and may consider the work trial together with the worker’s transferrable skills, education and occupational rehabilitation services.

Workplace rehabilitation services

Insurers may consider whether the worker has received any workplace rehabilitation services when assessing suitable employment options.

Workplace rehabilitation services may include job seeking assistance, resume development and interview techniques.

Vocational assessment

Insurers may use a vocational assessment when assessing suitable employment. These assessments are tailored to the worker and consider the worker’s skills, past work experience and whether the worker has transferable skills across a range of employment opportunities.

For example, a vocational assessment may include an analysis that identifies the worker has a skill set that is transferable into a different job role to the one where they received their injury and enables the worker to return to work in suitable employment.

Sometimes a worker may already be working in a particular role. If they are and the insurer would like to make a decision about whether that role is suitable employment, then information about the role should be provided in the report.

Suspending benefits due to refusal or non-participation

Where the insurer requires the worker to attend an assessment appointment and the worker refuses to attend or the assessment did not take place due to the failure of the worker to properly participate, the insurer may suspend the worker’s weekly payments.

Before suspending the payments, the insurer should be satisfied that it has sufficient information to confirm that the worker has refused to attend the appointment, or that the assessment did not take place due to the failure of the worker to participate.

The insurer should advise the worker that weekly payments will remain suspended until the assessment has taken place. Where suspension has occurred, the insurer should fast-track the new assessment appointment and advise the worker of the details.