Claims Management Explained – Step By Step
|Step 1||Prevention.||Taking steps to prevent workplace accident and injury is always the first course of action of effective claims management.|
|Step 2||In case of Injury.||Be sure you are aware of your legal obligations as required by the Occupational Health and Safety Act 2004 and Accident Compensation Act 1985.|
|Step 3||Team Action.||Remember, when an injury does occur, your insurer is committed to Working with you as part of your Claims Management team. For the best results, your Business and your WorkCover Insurer should take the following action in tandem.|
|EMPLOYERS ACTION||INSURERS ACTION|
|PROCESSING A NEW CLAIM|
|a. Take receipt of the Claim Form and Certificate of Capacity from the claimant
b. Complete an Employer Claim Form, document any additional claim issues and background.
c. Forward all relevant documentation to Insurer within 10 calendar days.
|a.Receive claim and assess liability within 28 days of receipt or 39 days from date lodged on employer (whichever occurs first).
b.Contact employer to discuss claims issues and background.
c.Contact employer and advise of decision regarding liability.
|IF THE INSURER DENIES LIABILITY FOR THE CLAIM|
|a. Receive Insurer’s written advice.
b. Return any unpaid accounts to worker.
|a.Provide employer with written advice of claim rejection.|
|PAYING THE CLAIM|
|a. Pay the first $682* of medical expenses incurred by the worker. (* Annually indexed amount)||a. Reimburse the employer for any compensation payments made in excess of the employer’s liability within 20 days of receiving notification from the employer.
b. Pay the first 10 days of compensation due to the worker.
|PROVIDING SUITABLE EMPLOYMENT AND/OR REHABILITATION|
|a. Have worker choose one of the Employer’s three preferred rehabilitation providers.
b. Liaise with the worker’s treating provider to establish the worker’s capacity for work and any medical constraints applied by the Doctor.
c. Implement a suitable return to work plan and offer of Suitable duties.
|a. Provide assistance in establishing suitable duties or appropriate rehabilitation.
b. Provide expert onsite advice upon request.
c. Examine proposed Return to Work Plan before it is issued.
|a. Advise Insurer of any changes in circumstances. If, for example, the worker returns to gainful employment or there is a change in earnings, these details should be forwarded to Insurer immediately.||a. Arrange for medical reviews or investigations where appropriate, in order to assess on-going entitlements.
b. Notify the employer prior to taking any of the action noted above.
|RESOLVING A CLAIM|
|a. Assist the worker to return to full time suitable employment as soon as possible.||a. Evaluate any medical advice.
b. Assist the employer in returning the worker to full time employment.
c. Where appropriate, cease the worker’s entitlement to benefit.