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Claims handling requirements

Workers compensation claims should be handled in accordance with these standards and guidelines from 1 January 2019.

SIRA created the Standards of practice, Workers compensation guidelines and Workers compensation medical dispute assessment guidelines to improve outcomes in the workers compensation system.

SIRA will help insurers to understand all the new requirements to support implementation in the first half of 2019.

Standards of practice: expectations for insurer claims administration and conduct

The Standards of practice will support and encourage insurers to have effective claims management practices to help deliver positive experiences and outcomes for workers, employers and the people of NSW.

They include overarching claims management principles that are intended to apply generally to all claims handling and administrative activities.

Individual standards also apply to a range of claims management topics and include principles, SIRA’s expectations and benchmarks.

All insurers are expected to comply with the principles from 1 January 2019. A transitional period will apply for expectations and benchmarks, during which time SIRA will undertake further consultation and refinement.

The standards are not a comprehensive suite of claims practices. Instead, they target insurer processes that can have the greatest impact on claimant outcomes.

Additional information and guidance is also available in:

  • Appendix 1 which provides useful context and links relevant to each of the standards
  • Appendix 2 which provides additional guidance information for insurers on a number of topics.

Note: the practice guidance information is not intended to be mandatory - it is additional information to assist insurers. The content provided is not exhaustive, and SIRA will continue to engage with stakeholders in 2019 to ensure that practice guidance material is fit for purpose and meets the needs of stakeholders.

New guidelines

Workers compensation guidelines

The standards are supported by streamlined and consolidated Workers compensation guidelines which were published in the Government Gazette on the NSW Legislation website on 21 December 2018.

The workers compensation guidelines replace the:

  • Guidelines for claiming workers compensation (1 August 2016)
  • Guidelines on injury management consultants (27 September 2012)
  • Guidelines on independent medical examinations and reports (13 March 2012).

SIRA developed the guidelines after conducting a comprehensive review of the claims handling framework in consultation with stakeholders.

The guidelines explain what insurers, workers, employers and other stakeholders must do in relation to claims under NSW workers compensation laws.

The new guidelines aim to support delivery of the objects of the Acts and regulation by informing and guiding insurers, workers, employer’s injury management consultants, independent medical examiners and other stakeholders on the process of claiming workers compensation in NSW. SIRA requires stakeholders to comply with relevant parts of the guidelines that apply to them.

The Workers compensation guidelines do not apply to:

  • coal miner matters, as defined in the Workplace Injury Management and Workers Compensation Act 1998
  • dust disease matters, as defined in the Workers Compensation (Dust Diseases) Act 1942
  • claims made under the Workers Compensation (Bush Fire, Emergency and Rescue Services) Act 1987.

The new guidelines were issued under section 376(1)(c) of the Workplace Injury Management and Workers Compensation Act 1998.

Medical dispute assessment guidelines

The Workers compensation medical dispute assessment guidelines replace the WorkCover medical assessment guidelines 2006, and complement reforms to the dispute resolution process.

They set out the procedures for the:

  • referral of medical disputes for assessment and appeal
  • procedures for assessment and appeal under chapter 7, part 7 of the Workplace Injury Management and Workers Compensation Act 1998.

The new medical dispute assessment guidelines were issued under sections 328, 331 and s 376 of the Workplace Injury Management and Workers Compensation Act 1998. Relevant parts of the Guidelines apply to insurers, health practitioners, legal representatives, SIRA staff, decision makers, courts and other dispute resolution bodies.

Guidelines revoked

SIRA has revoked the WorkCover interim payment direction guidelines 2009. Instead,stakeholders should refer to the Workers Compensation Commission’s practice direction no. 10 Interim payment directions for weekly payment of compensation or medical expenses compensation (30 October 2018).

Online platform coming in 2019

SIRA is building an innovative online platform to make it easier to access information about workers compensation claims management.

The standards, guidelines and practice guidance will be added to the platform when it is launched, and further practice guidance material will be developed on a range of case management topics.

More information

For more information, email policydesign@sira.nsw.gov.au or call 13 10 50.