3.3.5 After the second entitlement period
3.3.5.1 Post second entitlement period review | 3.3.5.2 Additional services after 130 weeks | 3.3.5.3 Determine entitlement after second entitlement period | 3.3.5.4 Worker can make application | 3.3.5.5 Process for application after second entitlement period | 3.3.5.6 Ongoing management | 3.3.5.7 Six monthly reviews | 3.3.5.8 Weekly payments for surgery post 130 weeks
A worker’s entitlement to weekly payments ceases after the second entitlement period unless specific conditions apply.
See: Weekly payment rates
After the expiry of the second entitlement period the Agent must continue to review the claim to determine the worker’s ongoing entitlement and that the worker’s capacity has not changed since the last review.
3.3.5.1 Post second entitlement period review
A review of a worker’s capacity, rehabilitation progress and future employment prospects is to occur after the expiration of the second entitlement period. The review can be conducted at any time and as often as may be reasonably necessary. There is however a requirement for an assessment to occur at least once every two years.
Case conference
Topics for discussion at the conference should include the pre-conference review findings and may include but are not limited to:
- current treatment regime and appropriateness
- capacity for employment
- rehabilitation progress
- future employment opportunities and
- retraining options.
The conference attendees (minimum of two) should agree and determine appropriate actions and strategy to be undertaken in line with the review findings and conference discussions.
Two year review
A full review must be conducted as often as may be reasonably necessary but at least every two years to assess the worker’s ongoing entitlement to weekly payments.
At each review assess:
- if the worker is still incapacitated for work
- if the worker’s incapacity for work is still materially contributed to by the injury for which liability is accepted
- the worker’s rehabilitation progress and
- the workers future employment prospects
- if the injury suffered was a temporary aggravation of an underlying or non work-related An injury/disease is work related if it arose out of or in the course of employment and the scope of employment. condition, the review must also consider if the effects of the aggravation have ceased
- medical and like services for appropriateness and relationship to the work-related injury.
An Agent can undertake a review before the mandatory two years if reasonable and/or necessary, for example:
- the worker’s certified capacity on the Certificate of Capacity Ongoing certificate is issued for up to 28 days and can be issued by a: medical practitioner, osteopath, physiotherapist, chiropractor. changes
- retraining has been successfully completed
- there is a surgery request or
- a new injury appears on a Certificate of Capacity.
Conduct review
Agents need to obtain all necessary up to date information in order to conduct a thorough review and make an informed decision on the worker’s ongoing entitlements such as:
- THP Treating Health Practitioner reports
- IME Independent Medical Examiner / Independent Medical Examination reports
- OR Occupational Rehabilitation reports
- vocational assessments
- worker interviews.
A properly conducted review will also identify any gaps or missing information for follow up.
Agents are required to develop a strategy/plan to assist the worker to return to work where possible as part of the review.
Review findings
A worker’s capacity may have changed since the last review. This includes workers who since the last review:
- have returned to work
- are considered to have a CWC Current Work Capacity although they have not resumed employment
- is a pre-12 November 1997 claimant A person who applies for WorkCover benefits. and are not classed as seriously injured or
- have an entitlement to weekly payments after the second entitlement period and have altered their hours of work or altered their work capacity.
Medical and like services are also reviewed to ensure there is still an ongoing entitlement to these services for the accepted injury. Consider:
- appropriateness of treatment and medications
- the frequency and amounts are appropriate
- if home help, aids and appliances are still necessary.
Alteration to entitlement
The review findings may establish:
- no ongoing entitlement to either weekly payments and/or treatment or
- an alteration to a current entitlement to weekly payments or treatment.
If the Agent decides to alter or terminate weekly payments or treatment, the Agent must send a notice to the worker and employer, ensuring:
- all criteria is addressed before terminating and
- the correct notice period is given.
Advise THP
The Agent advises the THP if the review has identified a need for:
- increased treatment
- other beneficial treatments or
- further investigations
Identified increases in home help or aids through independent assessments are to be made as soon as practicable, as long as guidelines are met.