3.3.5.5 Ongoing management post second entitlement period
After deciding the worker’s ongoing entitlement, the Agent or self-insurer should schedule the claim for ongoing review.
Information to be provided
The Agent or self-insurer should ensure they receive regular, clear and written information to assess the worker’s ongoing entitlement. This information includes:
- hours worked by the worker each week
- current weekly earnings
- Certificates of Capacity.
Information to be assessed
The information needs to be assessed to:
- determine if the worker continues to work the necessary hours per week
- confirm the worker’s capacity to work a minimum of 15 hours per week
- confirm the worker is earning at least $228 per week.
If the information provided indicates that any of the criteria are not being met, the Agent needs to determine if the worker continues to have an entitlement to weekly payments.
See: Six monthly reviews
If information is not provided
If the information is not received the Agent should contact the worker or their representative and advise them that weekly payments cannot be calculated until the required information is provided.
If the information is still not received within a reasonable timeframe, the Agent or self-insurer may review the worker entitlement.
See: Terminate weekly payments after second entitlement period.
Changes to worker’s status
If the information provided indicates that there has been a change in the worker’s work or medical circumstances a review will need to be conducted to determine the worker’s ongoing entitlements.
See: Terminate weekly payments after second entitlement period
Fluctuations in hours worked and/or increased current weekly earnings (CWEs)
Workers can have their hours worked or CWE Current Weekly Earnings fluctuate without their entitlement ceasing, provided it meets the acceptable criteria.
To determine if the fluctuations fall within the acceptable criteria, entitlements must be reviewed in consecutive 12 week blocks from the acceptance date of the section 165 application. If earnings or hours fluctuate for more than a 4 week period within one of the 12 week blocks, it is important to understand the reason to determine if the worker has an entitlement.
Acceptable reasons that should not impact the worker’s entitlement are limited to a short term increase in hours/CWE (e.g. approved leave, staff shortage/coverage, and small increase in seasonal workload).
The increase in hours/CWE must not demonstrate a significant deviation from certified capacity as determined at acceptance of the section 165 application, as this may warrant further review of ongoing capacity, and entitlement under the Act.
3.3.5.6 Six monthly reviews
Reviews should be conducted at least every six months.
Information for six monthly reviews
As part of the review Agents should consider a:
- review by the worker’s treating practitioner of whether the worker:
- continues to have no capacity to increase hours or take on additional work because of the injury
- is likely to continue indefinitely to be incapable of undertaking further or additional employment
- review by an independent medical examiner of whether the worker has a capacity to:
- take on additional work because of the injury
- is likely to continue indefinitely to be incapable of undertaking further or additional employment
- vocational assessment
- a vocational assessment could be used to assess the worker’s capacity to increase hours.
Outcome of review
If the review indicates that the worker has and is likely to continue to have, no capacity to increase their hours or take on additional duties, a further review should be conducted at either:
- six months from the date of previous review or
- at a date determined by the Agent to be more appropriate.
If the review indicates that the worker has a capacity to increase their hours, the Agent or self-insurer may review the worker's entitlement.
See: Terminate weekly payments after second entitlement period.