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Workers Compensation Injury Management

Management of Claims

While risk management can minimise the risk of injury, the possibility of zero injuries occurring indefinitely is remote. Therefore despite our best endeavours there will always be injuries that become claims. The size of the claim and the way in which it is managed has a direct bearing on future insurance premiums.

Insurers and employers, for a multitude of reasons, may fail to manage significant claims proactively and this leaves obvious scope for improvement. This is precisely where injury management can produce major reductions in the duration and subsequently, the size of significant claims, directly reducing premium loadings.

All stakeholders will benefit directly:

  • The worker.
  • The employer.
  • Service providers – rehabilitation, medical and various services for early resolution of the claim.
  • The insurance company or claims agents as agents of WorkCover.

Other factors or considerations that may impact on claims:

  • The worker, who needs to understand their obligations and know that they are part of the claim procedure (and that the employer is interested in them).
  • The employer, who must be proactive and manage all aspects of the injury, the claim and return to work so that early settlement of the claim is possible.
  • Service providers if they are to be truly effective, must work together as a team towards a healthy and early return to work. Each must collaborate and integrate their medical and practical solutions seamlessly into one plan.
  • The insurance company or claims agent, who must administer the team plan ensuring stakeholders’ responsibility and activity. It is the insurer or claims agent who takes the financial governance role in balancing claims costs and providing efficient injury and claims administration. This custodial role dictates that the insurer or claims agent honour their responsibilities to each of the stakeholders.

It is necessary to consider key control points some of which are:

  1. Educating the employer that aggravation of a pre-existing condition constitutes a legitimate claim. It is therefore imperative that employers ascertain knowledge of any pre-existing conditions so that they can adjust the duties of the employee, even before employment commences.
  2. Employees’ understanding that the employer bears the costs with respect to their claim and the impact it has on the profitability of the company (workers compensation is not a Government funded benefit).
  3. The rehabilitation provider - The sequence of assessing the claim:
  • Speed is essential. Dedicated call centres are set up in the rehabilitation providers office, manned 24 hours a day by experienced assessors. They will determine initially whether a claim is likely to be significant or non-significant. An assessor will, at the time of this phone call, complete the claim form on your behalf and also notify the insurance company or claims agent.
  • For claims with potential for an extended time loss all injured workers are interviewed at the employers’ premises, by appointment and general, injury permitting, within 48 hours or less. This interview is carried out by an assessor from the rehabilitation provider with the sole purpose of achieving the best outcome possible. The assessor needs to achieve certain objectives:
  • Inspect the accident site to see whether a dangerous situation exists and also whether the accident has been caused in the way reported.
  • Build goodwill between employer and employee.
  • Make the employee aware of the costs of the claim on the company.
  • Set up a back to work plan in consultation with the employer and the employee
  • If necessary the assessor will organise a further medical with a sports medicine specialist. It has been estimated that up to 90% of all workers compensation claims relate to the muscular skeletal system and this is traditionally the area of expertise where sports medicine doctors excel.
  • The assessor will then give his report to the insurance company or claims agent.
  1. The WorkCover agent must meet strict criteria
  • To appoint a designated team of case managers and staff.
  • To provide excellence in communication, relevant and timely information to all stakeholders.
  • Most importantly to always liaise and keep the employer informed.

It is the employer who pays workers compensation premiums. It is professional and timely advice that enables the employer to best manage the outcomes.

Key Partners

WorkCover Agents

Because the integrity of this type of system relies upon the partners’ ability to integrate efficiently and effectively, clients should only deal with those agents who have a proven track record of performance. As a minimum, clients should seek agents with designated teams to be appointed to ensure fast tracking of service and claims support. Claims must be reimbursed quickly and fairly.

The agents  ability to correctly set claims reserves, liaise with stakeholders and finalise claims is vital because wrongly reserved claims cause excessive premium loadings and unless challenged early, premium overcharging can not be refunded.

Therefore, only those agents with a positive focus on client service and who are solid financial institutions should be appointed.

Injury Assessors

Critical to the effective management of loss, is the ability to instantly identify and evaluate the seriousness of injury. Injury assessment is not the responsibility of the insurer or claims agent. They simply control premium charging and the claims paying service functionality. Injury assessment requires a dedicated support team of specially qualified injury assessors to evaluate and make immediate decisions on injury treatment.

The assessors need to be in a position to immediately assess the injury and decide whether it represents a significant or potentially significant injury. They should also be able to complete the claims advice for the WorkCover agent and handle the entire procedure. If necessary an on site employee/ employer meeting may be arranged within 48 hours where claims warrant this. The injury should be totally managed from the initial report to the medical treatment and return to work.

Workplace Health & Safety Consultants

While many businesses know this is compulsory in all states and have WH&S policies, many fail to have documented processes and systems in response to the legislation. Merely having a WH&S policy pasted up on the company staff room wall will not meet the legislative standard, particularly when a serious injury has occurred.

WH&S compliance is not just a strict legislative requirement but good risk management as well. Being able to identify what can go wrong, how it can go wrong and what can be done before it does go wrong, is the only way for business to operate today. Good WH&S strategies not only protect employees but also save premiums and may help avoid significant fines, legal expenses and costs.

Pre-employment medical providers

Part of any risk process is the identification of risks to be managed. Businesses should appoint consultants to complete pre- employment medical checks in order to identify potential employees who are not fully capable of performing the tasks set for them due to physical limitations or potential to sustain injury. In addition comprehensive medical examinations can and do reveal pre existing injuries or injuries that may be aggravated by the nature of the work to be performed. Completion of pre-employment medicals can avoid the risk to an employer of being saddled with an aggravated injury claim on his workers compensation insurance policy.

Legal Advisors

Because complex claims and complex injuries do arise, it is crucial to have the best expertise on call. In cases where there are serious injuries, evidence is taken by WorkCover inspectors and this evidence is prima face evidence used against the employer. Issues will be considered by the WorkCover agent such as whether the employer has a valid claim for indemnity or are there civil and criminal proceedings that may flow from this same accident.

Remember that Workers compensation authorities are required to not only police the compensations acts, but also the WH&S Acts and regulations. In many statutes these acts have been modified to include criminal prosecution, with the provision for very large fines for individuals including potential gaol terms for directors, principals or officers.

Appointed legal advisors should be industry leaders in legal advice and service for workers compensation and WH&S.

Find Us

Annis Group Pty Ltd
AFS Licence 243559

Suite 308 / 10 Century Circuit,
Baulkham Hills, NSW, 2153
PO Box 7366,
Baulkham Hills BC, NSW, 2153
Phone: 02 8852 8888
Fax: 02 8852 8899