Injury management program: a guide and checklist for insurers
Injury management
Injury management involves activities and procedures undertaken or established to enable workers with a work-related injury or illness to achieve a timely, safe and durable return to/recovery at work.
This guide will help insurers establish and maintain an effective injury management program in line with:
- Workplace Injury Management and Workers Compensation Act 1998
- Worker Compensation Guidelines
- Standards of Practice
For the purpose of this document, an ‘insurer’ refers to scheme agents of the Nominal Insurer, specialised insurers and self-insurers.
Injury management program
It is an insurer’s obligation to establish and maintain an injury management program.
‘co-ordinated and managed program that integrates all aspects of injury management (including treatment, rehabilitation, retraining, claims management and employment management practices) for the purpose of achieving optimal results in terms of timely, safe and durable return to work for injured workers’.
NSW workers compensation legislation requires insurers to develop an injury management program that should:
- detail how the insurer will achieve a coordinated and integrated process for injury management as defined in section 42 of the 1998 Act
- demonstrate a streamlined and transparent process for managing workplace injuries
- be presented in a planned and organised manner
- enable the insured businesses to develop a return to work program consistent with the insurer’s injury management program.
Insurer injury management program obligations
An insurer must lodge its injury management program and any revised injury management program with the State Insurance Regulatory Authority (SIRA).
A scheme agent also has an obligation under Section 43(1A) of the 1998 Act to revise its injury management program when directed to do so by the Nominal Insurer and lodge a copy of the revised program with the Nominal Insurer.
Section 43 of the 1998 Act describes the insurer’s injury management program obligations to:
- establish and maintain an injury management program and revise it from time to time, or when SIRA directs
- lodge a copy of its injury management program and any revised injury management programs with SIRA
- An insurer that is a scheme agent must lodge a copy of its injury management program (and any revised injury management programs) with the nominal insurer
- Give effect to its injury management program and for that purpose, comply with the obligations imposed on the insurer by or under the program
- take steps to ensure each employer (insured by the insurer) is aware of workplace injury management obligations
- implement the injury management program within three working days after being notified of a ‘significant injury’ to a worker, and make contact with the worker, employer and where appropriate, the worker’s treating doctor.
Claims management principles
An injury management program outlines insurer procedures to optimise results for claimants through the coordination of timely, safe and durable return to work, reasonably necessary treatment, rehabilitation, retraining, and claims management.
These procedures should be aligned with the claims management principles to achieve better claim management experiences and return to work outcomes for workers.
As a guide, the claims management principles outlined in the Standards of Practice include:
Principle 1: Fairness and empathy
The management of claims will be undertaken in an empathetic manner intended to maximise fairness for workers by:
- ensuring that workers understand their rights, entitlements and responsibilities, and making clear what workers and employers can expect from insurers and other scheme participants
- ensuring workers are afforded procedural fairness, and decisions are made on the best available evidence, focused on advancing the worker’s recovery and return to work.
Principle 2: Transparency and participation
Workers, employers and other scheme participants will be empowered and encouraged to participate in the management of claims by:
- ensuring transparent and timely communication of the reasons and information relied upon for decisions and facilitating right-of-reply and prompt, independent review of decisions
- ensuring opportunities are provided to workers, employers and other scheme participants to contribute information that can support and inform claims management.
Principle 3: Timeliness and efficiency
Claims management decisions will be made promptly and proactively, and claims will be managed in a manner intended to reduce delays and costs and maximise efficiency by:
- promptly and efficiently processing claims, responding to inquiries, determining entitlements and making payments
- progressing claims without unnecessary investigation, dispute or litigation.
Injury management program template
This template shows how an insurer may structure its injury management program.
For further detail about key elements that may be included in the injury management program, please refer to the injury management program checklist in the Appendix.
Injury management program for - insert insurer name
Introduction
A statement outlining the intent of the document.
References
Note the relevant legislation, SIRA guidelines and other sources of information used to develop the program.
Stakeholder obligations, rights and responsibilities
Outline the obligations, rights and responsibilities of key stakeholders.
Key parties may include the worker, employer, insurer, nominated treating doctor and any others deemed appropriate.
Return to work
Outline the assessment, planning, implementation and review procedures relating to return to work. For example, engaging workplace rehabilitation providers, identifying and using vocational rehabilitation programs.
Claims management
Outline the assessment, planning, implementation and review procedures relating to the management of a claim. For example, calculating pre-injury average weekly earnings, the dispute pathway for adverse liability and adverse work capacity decisions.
Treatment and medical intervention
Outline the assessment, planning, implementation and review procedures relating to treatment and medical intervention. For example, determining reasonably necessary treatment, and setting service expectations with providers.
Employer management practices
Outline the procedures to be undertaken to manage employer practices. For example, injury data analysis, developing improvement strategies with employers that have poor return to work outcomes.
Appendix – Sample injury management plan
Issue date: insert date here
Review date: insert date here
Appendix
Injury management program checklist
This checklist is consistent with section 42 of the Workplace Injury Management and Workers Compensation Act 1998, Workers Compensation Guidelines 2019 and the Standards of Practice. Use it against the injury management program to ensure it meets the definitions in the 1998 Act.
The checklist outlines the key elements that should be included in the injury management program. These elements should include information on:
- procedures that detail how each aspect will be managed
- the responsible person for any actions identified
- timeframe requirements.
The key elements of an injury management program may include, but are not limited to:
| Content | SIRA Reference | Included | Comments |
|---|---|---|---|
| Overview: | |||
| References to relevant legislation and guidelines | |||
| Overarching claims management principles | |||
| Stakeholder obligations, rights and responsibilities | |||
| Return to work and rehabilitation practices: | |||
| Managing employer obligations | |||
| Provision of workplace rehabilitation assistance | |||
| Claims management practices: | |||
| Notification | |||
| Worker consent | Standard 1 | ||
| Triage | |||
| Early contact | |||
| Interpreter services | Standard 28 | ||
| Assessment throughout the life of the claim | |||
| Injury management assessment | |||
Determine entitlement to benefits: |
| ||
| Planning throughout the life of the claim | |||
| Injury management planning | Standard 12 | ||
| Implementation and review throughout the life of the claim: | |||
| Injury management implementation and review | Standard 12 | ||
| Case conferencing | Standard 16 | ||
| Medical payments | Standard 10 | ||
| Wage reimbursements | Standard 7 and 8 | ||
| Reduction of payments in compensation | Standard 9 | ||
| Dispute resolution | Standard 22 | ||
| Finalisation | |||
| Section 59A notification | Standard 19 | ||
| Section 39 notification | Standard 17 | ||
| Retiring age notification | Standard 18 | ||
| Closing a claim | Standard 30 | ||
| Other | |||
| Claim handover | |||
| Information and records management | Standard 2 | ||
| Fraud | |||
| Factual and surveillance investigations | Standard 24 and 25 | ||
| Recoveries | Standard 6 and 23 | ||
| Medicare and Centrelink clearance | Standard 26 and 27 | ||
| Complaints management | |||
| Quality assurance systems | Claims Management Self Audit Manual | ||
| Management of death claims | Standard 31 | ||
| Treatment practices | |||
| Determining reasonably necessary treatment |
Standard 4 and 15 Part 4.2 Guidelines | ||
Injury management consultant Independent medical examinations Independent consultants | Standard 14 | ||
| Provider management | |||
| Qualified / accredited providers | |||
| Employment management practices | |||
| Providing education and information to employers about their obligations | |||
| Injury management program communication | |||
| Claims data analysis to identify opportunities for improvement | |||
| Injury prevention strategies | |||
For further information or help developing an injury management program, insurers should contact their SIRA Portfolio Manager.