Workers compensation system - January to March 2019 - explanatory note

Claim

A claim for workers compensation or work injury damages that a person has made or is entitled to make under the Workplace Injury Management and Workers Compensation Act 1998.

The injury or illness may be physical or psychological, but employment must be a substantial contributing factor to injury for compensation to be payable.

Note that police officers, paramedics, fire fighters, volunteer bush fire fighters and emergency and rescue services volunteers may be able to claim for injury suffered during journeys to and from work or place of volunteering without the need to show a real and substantial connection with employment.

This report includes claims from workers whose employer is uninsured. Where a split by insurer segment is shown, claims of uninsured employers are included with the Nominal Insurer segment.

This report excludes claims for:

• dust   diseases. These are administered by the Dust Diseases Authority.
• workers   who are self-employed.
• employees   of the Australian Government.
• a   member of the NSW Police Force who is a contributor to the Police   Superannuation Fund under the Police   Regulation (Superannuation) Act 1906

Active claim

An active claim is defined as a claim with any payment within a three-month period.

Reportable claims

All claims excluding administration error claims, claims closed with zero gross incurred cost, claims shared between two or more workers compensation agents/insurers and agent/insurer is not responsible for the management of the claims, and claims with payments only for recoveries, vocational programs or invalid payment classification numbers.

Claims with date entered into the insurer system in the reporting month and previous 12 months.

Records submitted

All records received from insurers across NSW.  This data excludes administration errors.

Lost time

Monthly average, over the last 12 months, of workers who had lost time.

Claim types

Claims reported in the reporting month, classified as either 'psychological injuries' for mental disorder claims or 'all non-psychological injuries' for all other claims

Psychological Injury (ies)

The range of psychological conditions for which workers compensation may be paid, including post-traumatic stress disorder, anxiety/stress disorder, clinical depression and short-term shock from exposure to disturbing circumstances.

Return to work rate

The Return to work (RTW) rate is the percentage of workers who have been off work as a result of their employment-related injury/disease and have returned to work at different points in time from the date the claim was reported (i.e. 4, 13 and 26 weeks for the SIRA Stats report).

RTW rates are calculated monthly for the last 13 months up to the date of data. The cohort for each RTW measure is based on claims reported in a 12-month period, with a lag to allow for claim development (i.e., the lag for the 4-week measure is 28 days; the lag for the 13-week measure is 91 days; and the lag for the 26-week measure is 182 days).

Calculation method for 4-week measure for November 2018 is given below as an example:

1. Total number of time lost claimants = Claims   reported from November 2017 to October 2018
2. Total number of claimants back at work in 28   days (based on work status codes 1, 2, 3 & 4) with any capacity

RTW Rate=b/a multiplied by 100

SIRA identified data quality issues with the accuracy and completeness of data submitted by the Nominal Insurer (NI). The data revealed a significant deterioration in the NI’s RTW performance. To address the data quality and potential performance concerns with the NI, SIRA carried out a Data Quality audit in December 2018 and commenced a Compliance and Performance Review in February 2019

Bodily location of injury / disease

The bodily location of injury/disease classification is intended to identify the part of the body affected by the most serious injury or disease. Only 1-digit bodily location of injury is used.

Mechanism of incident

Mechanism of incident applies to claims entered into the insurer’s system on or after 1 July 2011 and uses the Type of Occurrence Classification System, 3rd Edition (Revision 1) Australian Safety and Compensation Council, Canberra 2008.

Nature of injury /disease

The nature of injury/disease classification is intended to identify the type of hurt or harm that occurred to the worker. The hurt or harm could be physical or psychological.

Payment data

Payments made are based on the transaction date.  Payments with payment date within the reporting period.

Common Law (WID) payments

Lump sum payments for damages and common law legal expenses incurred by the worker or agent/insurer, pursuant to Part 5 Common Law remedies, Sections 149 to 151AD, Workers Compensation Act 1987 and Section 318H, Workplace Injury Management and Workers Compensation Act 1998.

WID stands for ‘Work injury damages’ and this term is used interchangeably with ‘common law’

Commutations

The actual gross amount of commutation awarded or agreed upon for the claim. This refers to compensation where a commutation of the claimant's right to compensation has been made by the insurer. The up-front lump sum payment is made to an injured worker in place of continuing weekly compensation award and future medical and hospital expenses, pursuant to Part 3, Division 9 Commutation of compensation, Sections 87D to 87K, Workers Compensation Act 1987.

Death payments

Funeral expenses, weekly payments for dependant children and lump sum payments paid to the dependants or estate of the deceased worker, pursuant to the Workers Compensation Act 1987 No. 70 and Workers Compensation (Dust Diseases) Act 1942.

Investigation payments

Payments for insurer and worker investigation expenses, pursuant to Sections 9A, 11A and 44A, Workers Compensation Act 1987 and Sections 45A, 330, 331, 337, 339 and 376, Workplace Injury Management and Workers Compensation Act 1998.

Number of workers receiving weekly benefits per month

Number of injured workers receiving weekly benefit payments excluding Section 39 claimants that exited the system until June 2018.

Other payments

Payments for repair to or replacement of artificial limbs and clothing because of the workplace injury, amounts paid to any approved interpreter service for English language assistance to the claimant, transport and maintenance expenses related to travel costs incurred by the worker and shared claim payments.

Lump sum (S66 and S67)

Section 66 payments are lump sum payments for the permanent loss or impairment of a specified bodily function or limb, or severe facial or bodily disfigurement, including interest, pursuant to Section 66, Workers Compensation Act 1987 and as provided by the Table of Disabilities or whole person impairment (WPI) and Ready-reckoner of Benefits Payable.

Rehabilitation payments

Payments for a single workplace rehabilitation service, a suite of services provided to assist a worker to RTW with the same employer, a suite of services provided to assist a worker to RTW with a different employer or travel costs of the workplace rehabilitation provider in the delivery of rehabilitation services, pursuant to Sections 59, 60 and 63A, Workers Compensation Act 1987.

Rehabilitation treatment includes the initial rehabilitation assessment, workplace assessment, advice concerning job modification, and rehabilitation counselling. Rehabilitation treatment does not include medical, hospital, physiotherapy or chiropractic treatment.

Weekly benefits paid per month

Weekly benefit payments paid to injured workers for incapacity excluding Section 39 claimants that exited the system until June 2018.

Weekly payments

Weekly payments paid to an injured worker for incapacity.

Compliance promotion and assurance

The count of individual cases within the reporting period that SIRA has undertaken a compliance assurance activity. These include proactive compliance assurance activities and assessments of referred cases of alleged non-compliance.

Escalated enforcement and fraud

The count of individual cases within the reporting period that SIRA has undertaken an assessment or investigation of alleged fraud or escalated matters consideration for an enforcement response.

Penalties and prosecutions

SIRA enforcement actions undertaken with the reporting period, including the issuing of infringement notices, recoveries of avoided premiums and prosecutions.

Benefits paid directly to workers

Includes weekly payments, common law, s66, death benefits, commutations and miscellaneous payments.

Benefits paid for services for workers recovery and return to work

Includes medical costs, allied health services e.g. rehabilitation payments to support claimants.

Insurer expenses

Includes administration and operating expenses, regulatory costs, investigations, insurer’s legal fees etc.

Affordability

A reflection of the cost of premiums for workers compensation as a percentage of the reported NSW wages bill.

The premium value used for the Nominal Insurer is calculated as total premium payable net of GST and levies, such as the dust disease levy and mine safety levy. The premium for self-insurers is deemed premium, calculated as wages covered multiplied by the premium rate applicable for the appropriate industry class.

The premium for Government self-insurers (TMF) is the value of the deposit contributions made by each member agency. The premium for specialised insurers is the gross written premium, net of GST and levies, such as the dust disease levy and mine safety levy.

Premium information is updated annually.

Enquiry

An enquiry is defined as a customer call regarding information or advice that is general in nature.

The number of enquiries received in the reporting period.

Complaint data

Is derived verbatim from reports from customers.  Whilst some data cleansing processes are undertaken by SIRA the reporting is verbatim from customers and may from time to time reference an incorrect insurer and/or insurer type.

The number of complaints received in the reporting period.

Level 1 complaints

A level 1 complaint is defined as a complaint received by frontline staff where an insurer is notified (via email) by the Customer Advisory Service on behalf of the complainant.

Level 2 complaints

A level 2 complaint is an escalation of an unresolved level 1 complaint.

Justice

Customers’ perception of how equitably, fairly and justly they were treated is an important measure of the performance of the system.

The SWA 2018 RTW survey included asking workers about their perceptions of equity. Workers rated their experience across these four broad dimensions of equity and perceived justice:

• distributive   justice, about the fairness of their compensation
• informational   justice, in receiving accurate and timely information about the   rationale for decisions
• interpersonal   justice, on whether they were treated with respect and sensitivity
• procedural   justice, about the fairness of the procedures used to determine the   outcomes.

Survey respondents rated their agreement with a range of specific attributes on a five-point scale. For the SWA 2018 RTW survey, a range of specific attributes were measured within each of these four dimensions, comprising some 15 attributes. A higher mean score denotes a higher level of agreement (or a higher perceived sense of justice/fairness).

Complaint types reported to SIRA

Complaints received in the reporting period, split by complaint type.

Case Management Practice: Insurer conduct / behaviour

Where there is a general enquiry or complaint about insurer behaviour or conduct e.g. poor communication, or the way the claim is managed by the insurer.

Communication

Clarity of insurer information.  When an insurer has made a request of a worker, and the worker doesn’t understand the request, or why the request was made.

Customer Service: Behaviour

Where the customer is dissatisfied with the behaviour of any stakeholder involved in management of the claim, e.g. insurer or provider.

External Decision: WCC Determination

Enquiry or complaint about a determination not being applied or complied with, e.g. consent orders not being paid

Independent Medical Examination: Guidelines

Where there is an enquiry or complaint regarding Independent Medical Examination (IME) guidelines, that is, where a worker believes the insurer is not adhering to the guidelines e.g. not being given 10 days’ notice to attend an appointment.

Licensed Insurers: Claims Lodgement

Any enquiry about how to lodge a claim.

Medical: Liability

Process /communication to determine liability including any reference to reasonably necessary treatment and s59A entitlement periods e.g. medical entitlements have not been approved and the worker believes they have not received the relevant communication.

Medical: Payments

Delay in payments to the provider or reimbursement to worker.

Medical: Timeframes

A worker has made a claim for medical treatment, but the request has not been responded to within legislated timeframes i.e. a decision has not been made within 21 days.

Weekly payments: Payments

Enquiry or complaint about delays in payments to the worker or reimbursement to the employer

Weekly payments: Calculations

Enquiry or complaint about the calculation of pre-injury average weekly earnings e.g. the worker not receiving correspondence detailing the calculation. Enquiry or complaint from exempt workers about their current weekly wage rate or average weekly earnings.

Weekly payments: Liability timeframes

Enquiry or complaint about the relevant timeframes to determine liability, e.g. when a worker has lodged a claim form, but a decision has not been made within 21 days.

Disputes lodged/finalised

Disputes lodged/finalised in the reporting period.

Dispute rate

The number of disputes lodged (internal review, merit review, procedural review and workers compensation commission disputes) in the reporting month divided by the number of active claims as at the end of the same reporting month.

Active claim

An active claim is a claim that has had any payment activity in the three months as at the end of the same reporting month.

Internal review

An internal review is a review of the work capacity decision by someone within the insurer other than the person who made the decision. The source of information for the number of internal reviews is the insurers’ submission data to SIRA.

Merit review

A merit review is undertaken by an independent decision maker at SIRA who conducts a merit review of the insurer’s work capacity decision and outlines findings and recommendations. These reviews are binding on the insurers.

Procedural review

A review by the Workers Compensation Independent Review Office (WIRO) can follow a merit review by SIRA and is a procedural review of the insurer’s work capacity decision.

Workers compensation commission

The WCC is an independent statutory tribunal that has jurisdiction to deal with a broad range of disputes. Most of the compensation dispute applications are Applications to Resolve a Dispute (Form 2), and may involve claims for more than one type of compensation benefit, including weekly payments, medical and related treatment, and permanent impairment.