2.6.1.1 Time limits to determine liability
When determining liability for a claim, strict time limits apply under the legislation. However, the Agent should attempt to determine liability as soon as possible after receipt of a claim.
Claims for weekly payments – employer lodged
The Agent has 28 days from the date of receiving a valid claim (Parts A and Part B) for weekly payments to:
- accept or reject liability
- give written notice of the liability decision to the worker.
- The worker must receive the notice on or before the 28th day.
If the notice is to be posted to the worker, send it at least four working days prior to day 28, using prepaid post.
Delivery notices
Electronic post
See: Service of adverse determination notices
Express post delivery
Express post does not guarantee service delivery within 24 hours and should not be relied upon.
Note: Liability must be determined on all claims for weekly payments, including claims that are under the employer excess.
Claims for weekly payments – where Agent notified of claim by worker
Workers are required to give or serve a claim for compensation on their injury employer. Workers who make a claim for compensation in the form of weekly payments can also notify WorkSafe or the Agent of the claim by providing copies of all documents that have given or served the claim on the employer.
The Agent has 39 days from the date the Agent or WorkSafe received a valid claim for weekly payments as a notification from the worker to:
- accept or reject liability and
- give written notice of the decision to the worker.
However, this time limit may alter if the employer forwards the claim form and Certificate of Capacity Ongoing certificate is issued for up to 28 days and can be issued by a: medical practitioner, osteopath, physiotherapist, chiropractor. before a liability decision being made. If the documentation is:
- forwarded by the employer within 10 days from the date the worker gave or served the claim on the employer - the Agent has 28 days from the date the documentation is received from the employer to determine liability
- not forwarded by the employer within 10 days from the date the worker gave or served the claim on the employer - the Agent has 39 days from the date the documentation is received from the worker to determine liability
The worker must receive the liability notice on or before the expiry of the legislative time limit.
Note: Liability must be determined on claims where the worker has notified the Agent of the claim, including claims that are under the employer excess.
Deeming rules for claims for weekly payments
If the Agent does not give written notice of its decision to the worker within the legislative time limit, the claim for weekly payments will be deemed to be accepted.
A claim for weekly payments can only deem where both a claim form and Certificate of Capacity have been received by the Agent.
| Type of claim for weekly payments | Documentation received by Agent | Timeframe for claim to deem | Act |
|---|---|---|---|
| Claim forwarded by employer within 39 days of receiving it from the worker | Claim form and certificate are received by the Agent at the same time | 28 days from the ARD Parts A and B of claim form |
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| Certificate is received by the Agent after Parts A and B of claim form | 28 days from the MCRD |
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| Claim forwarded by employer more than 39 days after receiving it from the worker | Claim form and certificate are received by the Agent at the same time | On the ARD Parts A and B of claim form |
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| Certificate is received by the Agent after Parts A and B of claim form | 28 days from the MCRD |
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| Claim lodged by worker (direct lodgement) (If the claim is lodged on WorkSafe or Agent, ARD is the day the claim is received by WorkSafe/Agent) | Claim form and certificate are received by the Agent at the same time | 28 days from the ARD |
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| Certificate is received by the Agent after the claim form | 28 days from the MCRD |
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| Worker notification of claim (Copy of the claim form and certificate must be received by the Agent at the same time) | Worker forwards copies of claim form and medical certificate to Agent after giving to or serving originals on the employer | ||
| Employer forwards documents to Agent within 10 days of WSD | 28 days from the ARD |
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| Employer does not forward documents to Agent within 10 days of WSD | 39 days from the ARD |
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Claims lodged directly by worker
The same time limit applies to claims lodged directly on either the Agent or WorkSafe.
The Agent has 28 days from the date the claim was received by the earlier of the Agent or WorkSafe to determine liability.
See: Claims lodged direct
Accept/reject MEO claims within 28 days
Agents are to accept or reject claims for medical and like services within 28 days of receiving the claim (both Parts A and B).
48 hours to send a collection statement
If a claim is given, served or lodged using a form that does not contain the collection statement WorkSafe's Worker's Claim Form contains a page explaining the privacy policy in relation to the management of a claim. This text is titled 'Collection of personal and health information to manage your claim'., Agents must send a collection statement within 48 hours of claim registration.
See: Receive a claim
Returning invalid claims within 14 days
If a claim with a defect, omission or irregularity is not returned within 14 days of the claim being given, served or lodged, then the normal time limits apply for accepting/rejecting a claim.
See: Receive a claim
2.6.1.2 Liability decisions
Separate decisions can be made on a worker’s entitlement to weekly payments and medical and like services.
Claims for weekly payments
The Agent must make a decision on the worker’s entitlement to weekly payments and medical and like services. This is a full liability decision.
If a decision is made to accept weekly payments then a worker’s entitlement to medical and like services must also be accepted. The Agent still needs to assess the reasonableness of a particular medical or like service or cost for ongoing services.
If a decision is made to reject the worker’s entitlement to weekly payments the Agent needs to consider if there is an entitlement to medical and like services.
Claims for medical and like expenses
If a claim is for medical and like services only, the Agent makes a decision on the medical and like services entitlement only.
If a claim is converted to a claim for weekly payments, the Agent must make a separate decision on the worker’s entitlement to weekly payments.
Limited acceptances
Limited acceptance determinations accept liability for a stated period and rejects ongoing entitlement within the one notice.
Agents should only use a limited acceptance determination to limit weekly payments and medical and like expenses, where evidence obtained supports either a worker’s injury having resolved fully or there is no ongoing incapacity from that injury.
Appeal rights
If liability for a claim or an entitlement is rejected, the worker may refer the matter to the Accident Compensation Conciliation Service.
See: Dispute resolution
2.6.1.3 Steps to determine liability
Follow these steps to determine liability on a new claim:
| Step | Agent action |
|---|---|
| Contact stakeholders |
Contact the:
|
| Conduct initial review |
Determine liability for new claims. An Agent can either:
Complete initial assessment review and record a file note. Consider potential recovery and common law (except for under excess time loss claims). Determine the ongoing involvement of the Agent RTW Specialist. Determine whether a motor vehicle was involved. If so, obtain police report details. |
| Collect further information |
Determine if a medical or an investigative report is required. If required arrange an IME appointment and/or circumstance investigation, within five working days of receiving the claim. If the accident involved a motor vehicle, establish if the worker was the driver of the vehicle. This information can be obtained from the police report (driver/passenger sequence number) or circumstance investigation report. Where the worker was the driver of the vehicle, it must later be determined if a drink/drug driving offence took place. |
| Make and communicate decision |
Within the required timeframe, determine liability and advise the worker in writing of the decision. If liability is accepted: 
Different acceptance letters are used depending on whether the claim is under or over the employer excess. Payment profile is set Review the payment profile and amend if required. Note: This activity can be undertaken in this segment or in another segment. PIAWE Calculate the worker’s PIAWE on standard time loss claims. If liability is rejected: If liability is rejected, record the reasons for the rejection. The reasons must be included in the notice to the worker. If insufficient information exists as at the time of determining liability and the claim is rejected on that basis, the Agent must complete a post decision review once the extra information is received. Refer below. Keep proof of service of the rejection notice on the claim file to confirm the notice was served within the legislative time limits. Proof of service includes:
The employer is also sent a notice outlining the grounds for the rejection however, the reasons must not be provided. |
2.6.1.4 Post Decision Reviews (PDRs)
A PDR is required where information necessary to make a decision (e.g. IME Independent Medical Examiner / Independent Medical Examination report or supplementary report, clinical notes, or circumstance report Reports produced by private investigators about the details of a claim.) has not been received by day 28, and a rejection was issued in the absence of this information.
The Agent must complete a PDR within 5 business days of receipt of the required information, and advise the worker and employer in writing by issuing one of the following letters:
‘maintain’ letter
‘vary’ letter
‘revoke and accept’ letter.
Where, in order to complete the PDR, there is a need for the Agent to request additional information which was not originally requested as part of the claim determination process (e.g. supplementary IME report), the Agent should do this as soon as possible to facilitate expeditious completion of the post decision review.
IME reports
IME’s are expected to provide their report to the Agent within 5 business days of the examination, as per IME Service Standards, unless it is agreed by the Agent and IME that the report is urgent. If the IME or supplementary report has not been received within the required timeframe, it is expected that the Agent follow up the IME report on the day following the due date to confirm the ETA of the report. If the Agent is not provided with an ETA or there is unreasonable delay, this should be escalated with the Provider Team at WorkSafe.
Circumstance report
If Agents are awaiting a circumstance investigation report and/or additional information from a circumstance investigation (e.g. additional statements, employer policy or other documentation), it is expected that they initially follow up the report on the original due date of the report. If the information is not available, the Agent and provider should agree on a reasonable timeframe for completion. The Agent is expected to follow up this information on the agreed date.
THP information
Where treating health practitioner (THP Treating Health Practitioner) information is considered critical to claim determination, the Agent should proactively follow up the information on a weekly basis and/or at a specific time agreed to with the THP/third party provider.
Where:
it is clear that this information will not be provided, and/or
the request has been outstanding for greater than 40 days and the Agent has exhausted reasonable efforts to follow the information
the task can be closed and the worker informed.
Note: Where the THP information is not considered critical to claim determination, and the claim was rejected in its absence, it should be clearly noted in the rejection letter that:
the THP information has not been received;
the onus is on the worker to follow up this information and provide it to the Agent
upon receipt of this information the Agent will complete a PDR.
2.6.1.5 Further enquiries to make a liability determination
For most new claims, enough information is provided during the initial contacts with the employer, worker and treating health practitioner (THP) to determine liability. If not:
- consider and document what information is needed
- start gathering the additional information immediately.
Further information
Further information that might need to be obtained:
- circumstance or other investigation
- IME
- THP reports including clinical notes
- advice from a Medical Advisor.
See: Independent medical examinations & reports
Additional information from an employer
There is often information available in the workplace which can help an Agent to assess a claim. Contact the employer:
- when early notification claim has been received to obtain the employer’s documentation
- to get additional relevant information
- clarify details provided by the employer or the worker
- if the employer has indicated that they do not accept the worker has an injury/condition which is work-related An injury/disease is work related if it arose out of or in the course of employment and the scope of employment..
If the employer has indicated the claim should not be accepted, immediately contact the employer (via telephone, facsimile or email) to ask for the employer’s reasons in full. The basis for the employer’s non-acceptance must be fully documented, reviewed and discussed with the employer.
Verbal advice or discussions should be carefully and accurately noted. If the Agent is relying on that advice to make a decision, the employer must confirm the advice in writing.
A circumstance investigation is only arranged if the employer has failed to produce adequate information about the circumstances of a claim.
Additional information from the THP
Where appropriate, seek a report from the worker's THP.
For complex claims with unresolved medical and treatment issues the Medical Advisor should be consulted.
Medical examination to determine liability
The Agent may need to arrange an IME to help determine liability.
The IME must be arranged so that the report will be received in time to determine liability.
A decision to reject a claim must not be based on a verbal report.
See: Arrange an independent medical examination
Determinations of a new injury or aggravation when dealing with pre-existing/degenerative condition claims
A diagnosis is not necessarily required prior to claim acceptance, where there is evidence that an injury or illness is work related. Agents are encouraged to use the paragraph under ‘What has been accepted?' in the Novus acceptance letter to support the early acceptance of the claim.
Determination on mental injury claims where all of the allegations are not substantiated
Following the investigation of a mental injury claim, if it is determined that the worker’s allegations have not been fully substantiated (eg allegations of bullying and harassment), however it is determined that the worker is entitled to compensation, Agents are encouraged to use the paragraph under 'What has been accepted?' in the Novus acceptance letter to explain the acceptance of the claim.
RTW strategy on pending claim
If liability is set as pending, complete the initial review.
To minimise the risk The probability of the worker not returning to work is known as the risk or risk factor. For example: if a worker is likely to return to work, the claim is categorised as low risk. of RTW Return to Work barriers developing, focus on developing a RTW strategy whilst further investigations are undertaken.
See: Return to Work
Early treatment & support – pending mental injury claims
See: 6.5 Provisional payments for a mental injury
2.6.1.6 Prior claim information
It may be appropriate for Agents to obtain information of a worker's previous claim if the information being requested is deemed relevant and necessary for the effective management of the current claim.
It is the responsibility of the requesting Agent to ensure that information requested is relevant and appropriate.
Circumstances where it may be appropriate to obtain previous claims information include:
- the worker has had previous similar injuries
- the worker may have a claim with another employer with the same date of injury.
Information that can be requested:
- written documentation – claim forms, IME and THP reports, ORP reports
- photographs/video
- information stored electronically.
Request information
When requesting information about other claims, the following information must be provided:
- the worker’s name, date of birth and address
- the claim numbers of the files required (identifying whether open or closed and standard or minor)
- details of information required (reports in the claim files).
Provide information
The other Agent managing the other claim must within 10 working days of receiving the request:
- locate the file requested
- if the file is in secondary storage, notify the requesting Agent
- retrieve the file if it is in secondary storage
- copy the relevant information
- forward requested information to the requesting Agent
Receive information
Upon receipt the requesting Agent must:
- acknowledge receipt of information requested
- review and copy information required from the claim file (if required) and return the claim file within five working days
2.6.1.7 After employer has exited scheme
When a new claim for an injury before the exit date is lodged or a request for reactivation is received the following procedures should be followed.
The Agent should assess whether:
- the injury was reported to the employer
- the claim could have been made before the employer’s exit date
- there is enough evidence that the claimed injury occurred before the exit date.
The Agent:
- makes stakeholder contact Contact involves the Agent initiating and continuing regular contact with the worker. Employer and the worker’s treating health practitioner. This develops a relationship between the parties, allowing the collective gathering of information and the relay of strategies and goals (and with the treating doctor if necessary)
- documents what evidence has been relied on when making the determination to accept or reject liability.
Note: A suitably qualified person (technical) or Team Manager is to authorise the decision to accept liability.
Request to reactivate claim
Where a request has been made to reactivate a claim the Agent must assess whether:
- there has been a continuation of the claim
- the injury is a new injury.
The Agent:
- makes stakeholder contact (and with the treating doctor if necessary)
- documents what evidence has been relied on when making the determination to accept or reject liability.
Note: A suitably qualified person (technical) or Team Manager is to undertake these steps before the claim being reactivated
Claims where liability has been accepted incorrectly
If the Agent has initially accepted liability for a new claim or reactivated a claim after the employer has exited the Victorian scheme for an injury incurred before the exit date and later finds out that liability has been accepted incorrectly, the Agent must:
- terminate entitlement for both weekly payments and medical and like expenses
- send termination notices
- seek recovery where applicable.
See: Terminate medical & like services
2.6.1.8 Liability accepted incorrectly
If the Agent has initially accepted liability for a new claim or reactivated a claim after the employer has exited the Victorian scheme for an injury incurred before the exit date and later finds out that liability has been accepted incorrectly, the Agent must:
- terminate entitlement for both weekly payments and medical and like expenses
- send termination notices
- seek recovery where applicable.
See: Terminate medical & like services