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Standards of practice

A pdf of these Standards is available here.

SIRA has developed these Standards to support and encourage insurers to have effective claims management practices that will help deliver positive experiences and outcomes for workers, employers and the people of NSW.

1. About the Standards

The State Insurance Regulatory Authority (SIRA) is the government agency responsible for regulating and administering the workers compensation system in New South Wales (NSW).

The following legislation outlines the rights, responsibilities and obligations of workers, employers and insurers, should a person suffer a work-related injury in NSW:

Context

Under section 23 of the State Insurance and Care Governance Act 2015, a principal objective of SIRA in exercising its functions is to provide for the effective supervision of claims handling and disputes arising under NSW workers compensation legislation.

SIRA has undertaken a comprehensive review of the current claims handling framework for workers compensation in NSW. Through this review, SIRA has developed the Standards of practice: Expectations for insurer claims administration and conduct (Standards). These Standards are supported by streamlined and consolidated Workers compensation guidelines (Guidelines).

SIRA’s objective in developing the Standards and revised Guidelines is to improve workers compensation system outcomes. By ensuring clear, consistent, accessible and enforceable expectations are set for all insurers, SIRA will guide insurer conduct and claims management.

It is important that workers are protected and that they receive appropriate, timely and respectful services and support. Similarly, it is important that employers are actively engaged in the claims process to support the worker with their recovery and return to work following an injury or illness.

SIRA intends to use the Standards and improved Guidelines to hold insurers accountable for the delivery of a high standard of service to workers and their families, carers, employers and other system stakeholders.

Purpose

SIRA has developed these Standards to support and encourage insurers to have effective claims management practices that will help deliver positive experiences and outcomes for workers, employers and the people of NSW.

The Standards require insurers to apply principles across a range of processes and procedures in claims handling and administration. The principles and expectations  target activities where it is known that insurer processes or procedures are impacting the worker claims experience. They may also seek to provide clarity where there is confusion or inconsistency among insurers, leading to inequitable compensation outcomes for workers and employers. They are not a comprehensive suite of claims practices.

The Standards contain overarching claims management principles. These principles apply generally, and operate to guide all claims management activity in order to meet the system objectives outlined in section 3 of the 1998 Act. The principles articulate a strategy built on:

  • fairness and empathy;
  • transparency and participation; and
  • timeliness and efficiency.

Application

For the purposes of section 192A of the 1987 Act, the Standards set out within this document form the claims administration manual (CAM).

The Standards form part of SIRA’s regulatory framework. All insurers are expected to comply with these Standards, except for Coal Mines Insurance Pty Ltd and the Workers Compensation (Dust Diseases) Authority (Dust Diseases Care).

However, adoption of the overarching claims management principles and any relevant Standard is encouraged by all insurers operating in the NSW workers compensation system.

Exempt categories of workers (‘exempt worker’)

The term ‘exempt worker’ refers to specific classes of workers for which most of the amendments made to the Workers Compensation Acts in 2012 and 2015 do not apply. These classes of workers include police officers; paramedics; fire fighters; rescue workers; and bushfire, emergency and rescue service volunteers.

Standards apply to exempt categories of workers unless otherwise indicated in the standard.

Scope

The Standards contain overarching claims management principles that are intended to apply generally to all claims handling and administration activities. They clearly state the outcomes insurers are to achieve in the administration of claims.

Individual Standards apply to particular claims management topics, and are presented in a way to make clear the following elements:

  • Principle: the broad principle to be adopted by insurers when dealing with a particular aspect of a claim.
  • Expectations: SIRA expectations for processes, procedures or methods to be applied in the handling and administration of claims relevant to that Standard topic.
  • Benchmarks: an indication of what claims activities or actions SIRA may use to measure insurer performance against expectations.

The Standards should be read in conjunction with the requirements of the workers compensation legislation, regulation and guidelines.

Additional information to provide context for each Standard is provided in Appendix 1.

Further practice guidance information is provided in Appendix 2. The information provided in Appendix 2 is intended to support and guide insurers.

Specific references to relevant legislative provisions or relevant links are made throughout. Words defined in the NSW workers compensation legislation have the same meaning in these Standards of practice.

Commencement

The overarching claims management principles and standard principles will take effect and apply to all claims from 1 January 2019. The principles will continue to apply until SIRA amends, revokes or replaces them in whole or in part.

A transitional period will apply for expectations, to ensure insurer systems, claims processes and procedures are updated to support implementation. Further consultation on and refinement of these expectations will be undertaken during this period.

After the transition period, directions to comply with these Standards may be issued to insurers under Division 4 of Part 7 of the 1987 Act, which will make contravention (breach) of a requirement of the Standards an offence under section 209 of the 1987 Act. Section 194(2) makes compliance with a direction to insurers a condition of an insurer’s license issued under the Act.