6.2.2.5 Suspend impairment process

These guidelines advise Agents on expected management of suspended claims to increase the accuracy and quality of an impairment assessment without undue penalty.

Following the reinstatement of a claim suspended, the period of time the claim is spent in suspension will no longer impact the age of the claim by means of deducting the period of suspension from the calculation of the ‘Unresolved Claim Age in Years’.

WIRC s201(1)
AC s104B(1D)

Define a 'suspended' claim

A suspended claim is an IB Impairment Benefits application made on or after 18/11/2004, which has then been suspended within 90 days from the Agent Received Date (ARD Agent received date) for one of the following reasons:

  • WorkSafe has insufficient medical information to determine the matters or
  • WorkSafe cannot make a determination because the condition of the injury of the worker is not stable.
When compliance with the suspension policy is not required
  • claim is not suspended in line with the legislation.
  • claim is deemed as being medically unstable or containing insufficient medical information outside of the first 90 days.
  • claim is suspended using a code other than 15 (90 days).
  • claim is suspended but does not form part of process flow A3: Suspended (excl Election to Common Law).
  • claim is suspended using code 15 (90 days) but is outside 90 days from ARD.

Back to top

Process

Follow these steps to manage a suspended claim.

Step Agent action
Determine whether a claim is eligible for suspension

Day count: must be within 90 days from ARD.

Insufficient medical information

WIRC s200(1)(a)
AC s104B(2)

This relates to insufficient medical information to determine the matters including liability, obtaining an impairment assessment, determining the degree of permanent impairment resulting from the injury and calculating any entitlement to compensation.

Insufficient medical information usually relates to insufficient treating medical information, medical records, post-operative reports and psychiatric/psychological treating medical information, however, this list is not exhaustive.

Insufficient medical information does not include matters within the control of the Agent such as inability to locate a primary file.

Each case must be considered on its merits as to what information is required to make an accurate determination.

There are circumstances in which a worker that has failed to attend multiple IIAs may have their claim suspended.

See: Independent impairment assessment (Worker Non-Attendance at IIA-HLA Policy).

Injury/condition unstable

For an IB application, stability refers to a permanent impairment that:

“is considered to be unlikely to change substantially and by more than 3% in the next year with or without treatment”

as stated on page 315 of the AMA Guides, 4th Edition.

This definition of stability should be used as a guide to assist in determining whether the condition/injury has stabilised, with consideration also given to the legislation which states that an assessment must be made:

“based on the worker’s current impairment as at the date of the assessment, including any changes in the signs and symptoms following any medical or surgical treatment undergone by the worker in respect of the injury”.

WIRC s55
AC s91(1A)

It is appropriate to regard an injury as unstable if the worker has recently undergone a surgical procedure and no post-operative report or medical documentation has been received to confirm current stability of injury. The post-operative information must be requested by the Agent.

It is not appropriate to suspend a claim if the worker is undergoing medical treatment which is thought unlikely to alter his or her impairment.

If it is determined that the injury is unstable, the claim should be suspended in line with the legislation.

WIRC s200(1)
AC s104B(1D)

Suspend a claim

The claim is required to meet one or more of the following criteria:

  • ensure that documents on file substantiate that the worker’s condition has not stabilised (ie worker to undergo further surgery or treatment).
  • evidence that the worker recently underwent a surgical procedure and no post-operative report or medical documentation has been received to confirm stability of injury.
  • medical information on file has been reviewed and it has been determined that further information is required to determine matters, with a file note detailing specific information required including from who and why.

In addition to the above, the following criteria must be met:

  • update ACCtion using suspension code 15 (90 days), including a detailed file note to support the reasons for suspension.
  • notify the worker within 90 days of ARD by way of a standard letter advising the reasons their claim for impairment benefits has been suspended and the Agents action plan to progress the claim.
  • evidence that an action plan to progress the claim has been implemented (if appropriate).
WIRC s201(1)
AC s104B(2)
WIRC s200(1)
AC s104B(1D)

Manage a suspended claim

It is expected that the Agent will manage each case on its merits and acknowledge that there may be circumstances in which there is both insufficient medical information and an unstable injury. Agents are expected to be aware of actions taken by the claims teams (ie determining whether a post-operative report has been requested, obtaining latest treating medical information and IME reports).

The minimum requirements for managing a suspended claim are identified as follows:

Unstable injury/condition:

  • file note at time of suspension detailing reasons for suspension, including reference to the evidence supporting decision
  • documentation on file substantiating workers condition as not stable
  • in cases where worker is to undergo surgery/further treatment, determine date/s this is to occur
  • obtain prognosis and anticipated timeframes for stabilisation (ie THP report, post-op report)
  • regular file reviews noted on ACCtion to monitor the progression of claim.

Determine a suitable timeframe for review of the claim. However, WorkSafe recommends the following periodic reviews of the information on file and case management action plan as a minimum:

  • once every three months following surgical intervention
  • once every two months for further medical treatment (non-surgical)
  • once every month for industrial deafness/asthma/mental injury.

If less time is anticipated for stabilisation, Agents should review the claim more regularly, as deemed appropriate on a case by case basis.

Insufficient medical information:

  • file note at time of suspension detailing information required to determine matters including liability, obtaining an impairment assessment, determining level of permanent impairment or calculating any entitlement (ie hospital records, THP report)
  • evidence on file of requests made to obtain this information
  • in cases where the requested information has not been received in a timely manner, evidence of reasonable attempts to follow up (ie file notes, correspondence) and use of available alternative avenues of seeking the required information.
WIRC s201(1)
AC s104B(2)

Reinstate a suspended claim

Within 14 days, the Agent must:

  • have sufficient medical information to determine the matters or
  • be able to make a determination because the condition of the injury of the worker has stabilised -
  • by notice in writing to the worker remove the suspension.

The suspension must be lifted within 14 days of confirming the stability of an injury or receiving the information required to progress a claim. Suspended claims must be reinstated before referring a worker to an Independent Impairment Assessment.

WIRC s200(1)
AC s104B(1E)

Business rules

Upon reinstatement of a claim on ACCtion and removal of that claim from the A3 process flow, the period in which the claim was suspended will be deducted from the calculation of the ‘Unresolved Claim Age in Years’ when the:

  • claim was suspended within 90 days of ARD and the Suspension Policy
  • suspended claim was identified in the process flow as ‘A3: Suspended (excl Election to Common Law)’ AND suspension code ’15 (90 days)’ used
  • claim is reinstated and removed from the ‘A3: Suspended’ process flow.

Suspended claims may be subject to review by WorkSafe to ensure the claim was managed in line with the Suspension Policy and reinstated.

For the Aged Claim Measure, the age of all claims will be determined by the ‘Unresolved Claim Age in Years.’

The reinstatement of a suspended claim will not alter the ‘Unresolved Day Count’ of a claim.

WIRC s200(2)
AC s104B(1E)

Definitions

Agent Received Date refers to one of the following options:

  1. The earlier date of the:
  • Agent date stamp on an IB application signed by the employer or
  • date of the fax as it appears along the top of the fax or the next working day, where the application has been acknowledged or signed by the employer or
  • date of the file note confirming contact with the employer who has acknowledged the IB application.
    1. (The employer can acknowledge the original IB application or the Agent may forward a copy of the IB application to the employer. The file note should state that the IB application was acknowledged by the employer).
    2. The date of the file note that indicates the Agent has confirmed that the employer has ceased trading and therefore that the Agent accepts service.
    3. A later date stamp where an invalid/defective form has been returned to the worker in line with Claims Manual procedure and later re-submitted by the worker.

    Any date between receipt of the initial IB claim form and the relevant date for that file as defined in points 1 to 3 above or a date specified as relevant by the Agent and justified by a file note on ACCtion, which must satisfy WorkSafe that the specified date is appropriate.

    See: IB Claims Management Policy

    Next | Back to top