3.4.1.3 Requests for reimbursement
Process requests for reimbursement | Process late request
A valid request for reimbursement depends on the individual circumstances of the claim. The employer must provide enough information to enable the Agent to determine the amounts to be reimbursed for the period claimed.
Requests within three months of paying the worker
The following information is required to enable the Agent to determine the amounts to be reimbursed to the employer for the period claimed:
- a valid certificate of capacity Ongoing certificate is issued for up to 28 days and can be issued by a: medical practitioner, osteopath, physiotherapist, chiropractor. for the period claimed and
- if the worker had NCWC No 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 work, either in the worker's
pre-injury employment or in suitable
employment, the employer must provide a written statement confirming that the worker was paid or the employer intends to pay the worker and the worker had not returned to work for the period for which reimbursement is claimed or
See: WorkSafe Compensation Reimbursement Request form - if the worker had a CWC Current Work Capacity but did not return to work, a written statement from the employer confirm that the worker was paid and the worker did not return to work during the period for which reimbursement is claimed or
- if the worker had a CWC and has CWE Current Weekly Earnings, a written statement from the employer that the worker was paid and the details of the amounts of current weekly earnings received by the worker for the period for which reimbursement is claimed.
Requests more than three months after paying worker
In addition to what is required for a request made within three months of making the payment to the worker, the employer must send written reasons for the delay to request reimbursement.
Reconciliation after request submitted but not paid by Agent
If the employer has already submitted a request for reimbursement for the period claimed and has not been reimbursed by the Agent, the employer must provide documented evidence to demonstrate that a request for reimbursement was made to the Agent within three months of making payments to the worker.
See: WorkSafe Compensation Reimbursement Request form
Process requests for reimbursement
When an Agent receives a request for reimbursement from an employer they must check whether the employer has applied for reimbursement within three months of making the payment to the worker.
If the employer has applied for reimbursement after three months from the date of payment to the worker, Agents must follow the procedure for late requests.
Monitor requests on active claims
If an Agent has not received a request for reimbursement from an employer on an active claim they must contact the employer to:
- ascertain the status of the claim
- remind the employer that requests for reimbursement must be lodged within three months of them paying the worker. Send a warning letter to employer.
Valid request for reimbursement
The Agent must check that the employer has sent a valid request for reimbursement before the request is processed.
See: Requests for reimbursement
Note: If the employer has failed to submit relevant information, the Agent should make reasonable enquiries to obtain information. Advise the employer that if the information is not provided within three months of making the payment to the worker the request will be treated as a late request.
Entitlement to weekly payments
The Agent must check that the worker had an entitlement to weekly payments during the period claimed in the request for reimbursement.
Process payment
Agents must use Certificate of Capacity Code / Payment form when processing payment. A copy of this form must be filed in the claim file with the certificate of capacity and the request for reimbursement.
The Agent must reimburse the employer within 30 days of receipt of a valid request for reimbursement from the employer.
See: Certificate of Capacity code / payment form
Finalisation of weekly payments
The Agent must liaise with the employer to reconcile requests for reimbursement with payments received before closing the claim file.
Process late request
A late request for reimbursement is any request for reimbursement submitted by an employer more than three months after the payment to the worker. Agents must send copies of the Reimbursement Request form to employers with the acceptance of claim letter.
See: Process reconciliation requests | WorkSafe Compensation Reimbursement Request form
Reasons for delay not provided by employer
If the employer has not provided written reasons for the delay in sending the request for reimbursement, Agents must write to the employer requesting written reasons and evidence of those reasons.
Delay considered reasonable
If an Agent considers the delay was reasonable the reimbursement should be processed.
The Agent must record the decision and the reasons why the delay was considered to be reasonable.
Determine reasonableness for delay
Agents must determine whether the reasons given by the employer for the delay are reasonable on a case by case basis, both objectively and fairly.
There can be no definitive list or prescribed set of criteria for a ‘reasonable delay’. Employers must establish that the delay was due to circumstances beyond their control.
Although each case needs to be assessed on its merits, examples of what may constitute ‘reasonable delay’ include:
- fire, flood or other major disaster at the employers workplace
- death or serious injury to the person responsible for seeking reimbursement where there are a very small number of employees
- major industrial action (within 30 days after the payment made to the worker).
Examples of what would not constitute ‘reasonable delay’ include:
- employer ignorant of its obligations
- employer is too busy or has more important things to do
- employer contracted a consultant to manage the claim.
The onus is on the employer to satisfy the Agent that the delay to seek reimbursement was reasonable.
Decision to reimburse late request for reimbursement
Any decision to reimburse an employer where a request for reimbursement has been made more than three months after the employer made the payment to the worker must be made by the Technical Manager The Technical Manager liaises with Case Managers, employers, workers and legal providers to support the management of a workers' compensation claim./Team Manager or above.
See: Process requests for reimbursement
Delay is not considered reasonable
If any Agent is not satisfied that the employers delay was reasonable, the Agent must write to the employer to seek further information. Use the Reason for delay in seeking reimbursement letter.
- advising them that the reasons provided are not considered reasonable
- giving the employer the opportunity to provide further information
- confirming that unless further information is received upon which the Agent concludes that the delay was reasonable, reimbursement will not be paid.
If further information is provided by the employer, available information must be assessed to determine if reimbursement should be paid. If the Agent is still not satisfied, they must inform the employer that the delay is not reasonable and reimbursement will not be paid.
Inform the employer of the decision not to reimburse
A standard letter will be generated and sent to the employer about the decision not to reimburse weekly benefits for a period whenever reason code 210 or 211 selected.
The Agent must type in the reasons for not reimbursing the employer.
Approval to change a recorded decision
If a decision has been recorded not to reimburse an employer and the Agent wants to reverse that decision, the Agent must contact WorkSafe and:
- provide reasons why the original decision needs to be changed
- obtain approval to change the decision.
The outcome of the request must be recorded on the claim file.