3.3.5.2 Additional services after 130 weeks
The following additional services may be provided to help workers who continue to have an entitlement to weekly payments after the second entitlement period.
Occupational rehabilitation
OR Occupational Rehabilitation services can be vital to achieve a safe and sustainable return to work. Agents are expected to assess and actively manage those workers identified as suitable candidates.
See: Approve occupational rehabilitation services | A guide for employers - What to do if a worker is injured
For workers injured between 12 November 1997 and 19 October 1999, see ICRP Intensive Case Review Program settlements
3.3.5.3 Application for weekly payments after the second entitlement period - incapacitated due to surgery
Limited weekly payments following surgery
A worker who sustains an injury on or after 5 April 2010 may apply to the Agent or self-insurer to receive up to 13 weeks of weekly payments after the second entitlement period if they require time off work for surgery for their work-related An injury/disease is work related if it arose out of or in the course of employment and the scope of employment. injury.
If the application is accepted, the worker may receive weekly payments for the period of incapacity resulting from or materially contributed to by the surgery for up to a period of 13 consecutive weeks commencing on the day on which the surgery is performed.
Criteria
To be entitled to limited weekly payments for surgery the worker must meet all these criteria
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have suffered an injury arising out of or in the course of employment on or after 5 April 2010
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have received weekly payments until the expiry of the second entitlement period (104 or 130 weeks, depending on the worker’s date of injury)
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have returned to work for at least 15 hours per week and have CWE Current Weekly Earnings of at least $228 per week (indexed annually)
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either not be entitled to weekly payments due to the expiry of the second entitlement period OR be entitled to the continuation of weekly payments after second entitlement period due to a return to work
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not have had their entitlement to weekly payments terminated on the basis of having no entitlement
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not have received weekly payments (except where there is an entitlement to weekly payments after the second entitlement period) for at least 13 consecutive weeks after the expiry of the second entitlement period
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not apply for weekly payments for surgery until 13 weeks post the 130 weeks second entitlement period
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have obtained the agent’s or self-insurer’s acceptance of liability for the surgery
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not reached retirement age before the surgery occurs (the worker is able to reach retirement during the limited period of weekly payments)
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suffer an incapacity resulting from or materially contributed to by the surgery.
Ongoing weekly payments following surgery for claims reaching 130 weeks on or after 31 March 2024
For claims reaching 130 weeks after 31 March 2024, a worker may apply to the Agent or self-insurer to receive ongoing weekly payments after the second entitlement period if their capacity and impairment deteriorates because of surgery for their work-related injury.
In response to the application, the Agent or self-insurer will need to review the capacity assessment and the WPI Whole person impairment, even where made by an IIA Independent impairment assessment. This is the only time an earlier IIA’s impairment assessment can be reviewed.
Following the review, the Agent or self-insurer will need to make an ongoing eligibility determination either accepting or rejecting the application.
If the application is accepted, the worker will receive ongoing weekly payments —
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if the worker receives compensation under section 164 as a result of the subsequent surgery, the date that is 13 consecutive weeks after the day on which the subsequent surgery was performed; or
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in any other case, the date on which the ongoing eligibility determination is made in response to the review.
Criteria
To be entitled to limited weekly payments for surgery the worker must meet all these criteria
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have received weekly payments until the expiry of the second entitlement period (104 or 130 weeks, depending on the worker’s date of injury)
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either not be entitled to weekly payments due to the expiry of the second entitlement period OR be entitled to the continuation of weekly payments under section 165
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not have had their entitlement to compensation terminated on the basis of having no entitlement
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not have received weekly payments (except where there is an entitlement to weekly payments after the second entitlement period) for at least 13 consecutive weeks after the expiry of the second entitlement period
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not apply for weekly payments for surgery until 13 weeks post the 130 weeks second entitlement period
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have obtained the agent’s or self-insurer’s acceptance of liability for the surgery
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not reached retirement age before the surgery occurs (the worker is able to reach retirement during the limited period of weekly payments)
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as a result of the surgery, suffered an incapacity for suitable employment which is likely to continue indefinitely and have an whole person impairment of 21% or more.
3.3.5.4 Application for weekly payments after second entitlement period – returned to work
A worker with a current work capacity Under the legislation, unless inconsistent with the context or subject-matter — current work capacity, in relation to a worker, means a present inability arising from an injury such that the worker is not able to return to his or her pre-injury employment but is able to return to work in suitable employment, declared training program (CWC Current Work Capacity) may apply to receive weekly payments after the second entitlement period provided they satisfy all four of the following criteria:
- work at least 15 hours per week
- have current weekly earnings of at least $240 (indexed annually)
- are incapable of undertaking further additional employment or work which would increase their current weekly earnings.
- the likelihood that the worker’s current level of capacity is likely to continue indefinitely, that is, the current level of capacity will not improve in the foreseeable future.
For claims that reached 130 weeks on or after 31 March 2024, a worker must also have a WPI of 21% or more.
For pre-12 November 1997 claimants, see: Pre 12 November 1997 claims - weekly payments
Process for application after second entitlement period – return to work
Follow these steps to manage an application for weekly payments after the second entitlement period:
| Step | Agent and self-insurer action |
|---|---|
| Advise worker |
Write to advise workers who have weekly payments terminated after the second entitlement period of their right to apply for a continuation of weekly payments. The notice should include an explanation of the eligibility criteria that a worker must satisfy to be eligible for continuing weekly payments beyond the second entitlement period. If the Agent or self-insurer is satisfied at the time of issuing the notice that the worker may meet the criteria then an Application for Weekly Payments after the Second Entitlement Period form should be provided with the notice. |
| Worker makes application | If a worker thinks they meet the criteria, the worker must make an application to the Agent or self-insurer. |
| Review application | Send an acknowledgement letter to the worker. Contact the worker if further information is required to assess the application. |
| Determine eligibility |
Review the worker’s application and establish the worker’s eligibility. Workers with a date of injury on or after 5 April 2010 The Agent or self-insurer has 28 days from receiving the worker’s application to write to the worker advising if the application has been approved or rejected. If the application is rejected the agent or self-insurer must give the worker a statement outlining the reasons for the decision. Workers with a date of injury before 5 April 2010 The Agent or self-insurer has 90 days from receiving the worker’s application to write to the worker advising if the application has been approved or rejected. I f the application is to be rejected on the grounds the agent or self-insurer is not satisfied the worker’s current level of capacity is likely to continue indefinitely, the Agent or self-insurer must first refer the relevant medical question to the Medical Panels for an opinion. If the application is rejected the Agent or self-insurer must give the worker a statement outlining the reasons for the decision. |
| ACCtion coding |
S93CD/S165 application must be coded in BA01 and updated in BA02. The 130 week termination coding must remain active in CE03, however an end date will need to be added in order for payments to be made. The end date must be the day before the benefit application effective date (e.g. s165 benefit application effective date is 23/3/2022, therefore termination end date should be coded as 22/3/2022). When coding the application in BA screens do not enter an end date. The end date is only to be completed if/when payments cease. To cease payments, update the end date in BA02, this will be the effective date of the termination. By updating the end date it will automatically create an ineligibility record with termination reason code 156 - cease S93CD/S165 payments. This record can be viewed in ECE05. |
| Disputes - medical panel referral |
Where a claim has reached 130 weeks on or after 31 March 2024 and the worker only disputes the WPI determination in the decision, the Agent or self-insurer must refer a WPI question to the Medical Panels within 14 days of receiving the worker’s advice. Where a claim has reached 130 weeks prior to 31 March 2024, or where the worker disagrees with more than the WPI, the worker can lodge a Request for Conciliation. If a medical question arises in a dispute about a worker's entitlement to weekly payments after the second entitlement period, the Conciliation Officer must refer the medical question to the Medical Panels within seven days of becoming aware of the medical question. The Agent or self-insurer must bear the costs reasonably incurred by a worker for the referral to the Medical Panels. The relevant medical question to assess an application for weekly payments after the second entitlement period is defined in the legislation. This question has two main components:
Where relevant, a WPI question must also be referred to the Panel. |