Workers Compensation Claims – to review or not to review?
It seems just about everyone has heard a workers compensation horror story,- a claim that was accepted which shouldn’t have been or vice versa. Theatrical news reports and television shows regularly portray injured workers as calculating con-artists ‘caught’ on hidden cameras and confronted about their dishonesty.
The reality of the no fault statutory workers compensation system is that insurers have limited resources for claims investigation and generally make their decisions on the basis of the information provided by the worker, employer and medical professionals.
Insurers must consider a number of points within specified timeframes when deciding whether to accept or deny a claim. These include time limits, employment, worker status, whether the injury was caused by a work related event, and whether employment was a significant contributing factor (or major significant contributing factor for a psychological injury claim).
In relation to claims for psychological injuries the insurer must also be consider whether the claim arose out of reasonable management action or perception of reasonable management action.
So what do I do If disagree with a claim?
As an employer, if you have a concern regarding any aspect of a workers compensation claim it is essential that this information is provided to the insurer. Ideally this should happen during claim lodgement and prior to the decision being made on the claim.
It is recommend that you submit these concerns in writing to the insurer. All information submitted should be objective and respectful of the injured person. Rather than simply disagreeing with the claim it is important that your concerns are expressed in terms of the specific issues the insurer must consider such as whether the injured person is considered to be a ‘worker’ pursuant to the legislation or whether the injury claimed for is work-related. If your concerns are that the injury is not work-related be prepared to provide information and or documentation supporting this.
They still accepted the claim -what now?
If an insurer accepts a claim despite your submissions during the claim lodgement process and you are aggreived, you should request reasons for decisions from the insurer. This will help you understand the information they have considered in making the decision. It may be at this point that you decide that whilst you are unhappy with the decision, you understand why it is the case and proceed no further. On the other hand, you may disagree with the insurers interpretation of the information available and wish to lodge a review of the claim decision with the workers compensation regulator.
Some of the issues we recommend you consider prior to lodging a review include:
- The reasons for the review
- Cost /benefit (consider current and future cost of claim, potential for common law claim)
- Impact on the injured worker/broader workforce
- Likelihood of success
- Who will prepare and submit review documentation (this can be a time-consuming task)
- Is external assistance required?
Don’t lose sight of the big picture!
Keep in mind that it is possible to disagree with a claim and still facilitate a successful return to work program for the worker. This is a mutually beneficial result as return to work has been proven to assist recovery from injury and illness and it also reduces claims costs which impact workers compensation premium.
At HR Business Direction we are able to assist you with workers compensation claims and reviews. Contact us here.
Relevant blogs: Understand your rights as an employer; Don’t let a workplace injury let your relationships sour;
Christina Willcox MHSc; PostGradDip OHS; BBus(HRM)
Workplace Health & Safety Specialist
christina.willcox@hrbd.com.au
07 3890 2066
www.hrbd.com.au
