2.5.3 Check a claim
2.5.3.1 Check if claim is valid | 2.5.3.2 Check details before registering | 2.5.3.3 Identifying the correct employer | 2.5.3.4 Claims with multiple employers
2.5.3.1 Check if claim is valid
Agents must check if the claim is valid.
See: Valid claims
Minimum information required to determine claim validity:
| Purpose | Information | Use | Methods for accessing information |
|---|---|---|---|
| To verify worker |
Full name Date of birth Gender Address Contact phone number |
Essential to: confirm the identity of the worker enable necessary contacts to be made |
|
| To identify the employer | Business name Address of business Employer contact name Contact phone number | Essential to: verify the information provided on the claim form link the parties (worker and employer) | |
| To identify the incident/injury | Injury sustained Incident details (how it occurred) Date of injury | Injury and incident details are essential to start claim liability determination process |
|
| Declarations |
The ‘Authority to release medical information and worker’s declaration’ must be signed by the worker for the claim to be considered valid For electronically signed claim forms/myWorkSafe see 2.2.1 Worker completes claim form |
2.5.3.2 Check details before registering
The Agent must check if:
- the employer has a registered policy with that Agent
- a worker ID already exists. If so, note their ID number. If no worker exists, create a new worker ID
- a claim for the same injury/injury date has already been registered. If yes and the claim already recorded is a worker notification of a claim, ACCtion needs to be updated with the additional claim details.
The new claim documentation from the employer is placed on the existing file and ACCtion updated with any additional information provided by the employer.
See: Claim service and lodgement dates | Worker notifies Agent of a claim
Prepare coding sheet
Agents are recommended to complete a coding sheet as per their usual internal work practices.
Request prior claim information
Where it is appropriate the Agent may request prior claim information if it is relevant to the effective management of the current claim.
Stakeholder contact where claim lodged directly with Agent
The Agent contacts the worker and employer to confirm that the claim has been served on the employer.
If it has, the Agent should:
- verify with the worker how and when they served the claim on the employer
- verify with the employer how and when they received the claim
- remind the employer that they must forward the original claim documentation to the Agent within the required timeframes.
If the claim was not served on the employer, the claim may be invalid or be lodged under direct lodgement.
See: Invalid claims | Claims lodged direct
Mandatory information
If the information required to register the claim into ACCtion is not available, the Agent must request the information to complete the claim.
If a claim contains missing information Agents must:
- check if the information is contained in the:
- Employer’s Claim Report
- Certificates of Capacity
- contact the employer/worker to gather the required information
- consider contacting the treating practitioner to ask them for the information
- make a note on the file of the answer/s
- request written confirmation of the answer/s.
Upon claims registration or initial contact, the Agent is responsible for capturing and recording the worker's informed consent for digital transmission of personal and health related information by email and SMS. The informed consent may be provided by the worker in the claim form, or if the consent preference is missing, it is the Agent's responsibility to capture the consent upon initial contact.
See: Capturing informed consent for digital communication by email and SMS
Claim registered as incomplete
If a claim is registered as incomplete the Agent must follow up with the employer or worker to ensure that written confirmation is received within the time limits.
If a motor vehicle was involved
If the claim for compensation is made in respect of an injury resulting from an accident involving a motor vehicle, the Agent must check with the TAC Transport Accident Commission to ascertain if a claim has also been lodged with the TAC for the same incident.
The Agent must check for proof that any accident involving a motor vehicle has been reported to the police. If there is no evidence on the claim form or accompanying the claim then the Agent contacts the worker or employer to verify that a police report has been made.
See: TAC recoveries
2.5.3.3 Identifying the correct employer
If the Agent receives a claim from a worker and it is not clear who is the liable employer, the Agent is to help the worker identify the correct employer and Agent.
If the other employer is allocated to a different Agent, the Agent must:
- notify them that a claim has been received
- ask the other Agent to provide any relevant information.
The Agent must contact the other employer/s so they can provide any information they consider relevant.
To avoid breaching the privacy legislation, Agents must restrict the information given to the other employer to the:
- worker's name
- nature of injury
- date of injury.
See: Access to Information & Privacy
2.5.3.4 Claims with multiple employers
In some instances claims may be received from workers employed by more than one employer. Liability might involve more than one employer or it might be difficult to determine which employer is liable.
Which employer to register claim with
Register the claim against the employer the claim was given to or served on, even if it was served on the wrong employer.
If the worker serves claims on multiple employers for the same injury, claims are registered separately and liability determined against each employer.
The Agent who received the claim should conduct all enquiries.
See: Identifying the correct employer
Where the claim has been served on the wrong employer
Reject the claim if it is clearly established that the worker is entitled to compensation but has served the claim on the wrong employer. Provide appropriate assistance to the worker to enable them to identify the correct employer.
Where a valid claim has been served on multiple employers
If the employers are allocated to the same Agent
If it is determined that the claim:
- was registered against the correct employer, the normal assessment procedures must be followed and the Agent:
- registers each claim and assesses liability on each claim
- where a claim is accepted, advise the employer and worker
- where a claim is rejected, advise the employer and worker.
If employers are allocated to different Agents
If liability can be agreed on: the Agents involved must liaise between themselves to determine which employer is liable. The same procedures in regard to notifying the employers of the decision and the reallocation must be adopted as outlined above.
If liability cannot be agreed on: the following action will be undertaken by the Agent:
| Step | Agent action |
|---|---|
| Where an Agent receives a claim for compensation and considers that its client should not be liable to pay that compensation because another employer is liable, the claims staff must promptly notify the Senior Legal Manager and where possible, at least seven days before any rejection notice is issued.
The SLM must review the claim to determine whether the intended rejection is appropriate in the circumstances before any rejection notice is issued. |
|
| SLMs to discuss claim | Where the SLM considers that the grounds for rejection (based on another employer’s liability) are sound, that SLM contacts the SLM of the other relevant Agent to discuss the claim and the worker’s entitlement. The Agents must engage in full and frank discussions about the claim and make every reasonable effort to resolve the dispute and ensure that the worker receives the compensation to which they are entitled. |
| Operation Managers to contact Claims Branch at WorkSafe | Where the SLMs are unable to reach agreement as to which employer is liable to make payments, the Operation Manager’s must advise the Claims Branch at WorkSafe of the dispute before any decision to reject the claim is made. A conference at WorkSafe may be scheduled to discuss the claims. If the claim is for Impairment Benefits, refer it to the Manager, Impairment Benefits at WorkSafe. If a conference is arranged Agents must provide to WorkSafe copies of all relevant documents together with a brief (no more than one page) submission of the arguments in support of the position adopted by that Agent at least 24 hours before the conference. The SLM must ensure that all relevant claims staff, Agent management and where appropriate, the worker and employer are aware of the dispute and understand the nature of the process designed to resolve the dispute. |
WorkSafe may meet with operation managers
The Manager, Claims Branch of WorkSafe will meet with the Operation Managers to discuss the claim. In the unlikely event that the parties are unable to reach agreement about the worker’s entitlement and employer liability, WorkSafe will either:
- direct the relevant Agent to:
- make payments of compensation or
- in the case of Impairment Benefits accept liability and proceed to arrange the appropriate Impairment Benefit assessment/s or
- where the worker is not entitled to compensation, the Agent must make an appropriate decision on liability.
Outcome of conference
Once the dispute has been resolved, the responsible Agent must ensure that any payments are made within seven days of the conference.
If it has not already done so, the Agent of the employer considered not to be the injury employer must issue the appropriate written notice.