Claims and injury management

Overview

The injury management plan allows stakeholders to work together to establish a goal for the worker and define the activities, agreed actions and follow-up points required to achieve this goal.

The plan also sets out stakeholder obligations and provides the framework for the claim strategy. When developed and used correctly, it can be a helpful aid in the worker’s recovery and return to work.

Injury management planning is to be undertaken in a timely and proactive manner to support a worker’s treatment, rehabilitation and return to work.

This guidance considers the purpose of an injury management plan (IMP) and the obligations of the various stakeholders.

When to create an injury management plan

An insurer must establish an injury management plan for a worker when it appears that the worker has a significant injury as defined in section 42(1) of the Workplace Injury Management and Workers Compensation Act 1998 (1998 Act).

An injury is considered significant if it is likely to result in the worker being incapacitated for work for more than seven consecutive calendar days, whether the incapacity is total or partial, or a combination of both.

The IMP should be developed promptly once it first becomes apparent that the injury is likely to be a significant injury - see Standard of practice S12. Injury management plans for benchmarks.

The insurer is to provide both the employer and the worker with information regarding the IMP.

Who should the insurer contact?

The IMP must be established in consultation with the worker, employer (except where the employer is a self-insurer), and the treating doctor, to the maximum extent that their co-operation and participation allow (section 45 of the 1998 Act).

The insurer should contact the worker and the employer to:

• explain the IMP and its role in the workers recovery and return to work
• develop the IMP goal
• devise actions tailored to the worker and their goal.

The insurer should also contact the nominated treating doctor if treatment options are not clear, or there is confusion regarding the appropriateness of the goal.

What should an injury management plan include?

An IMP must include key information relating to the plan’s goals, actions, review points, as well as stakeholder rights and obligations and be tailored to the worker’s specific circumstances.

The insurer should consider how to best present this information so that the IMP is not overwhelming.

Identifying information

An IMP requires identifying information. Ideally, this should include:

• the worker’s name
• claim number
• date of birth
• injury
• date of injury
• employer details
• nominated treating doctor details.

Goal

In most cases this will be a return to work goal. However, depending on the type of injury, it may be focused on regaining independence or shorter-term recovery goals.

Actions tailored to the worker and their goal

The plan should include actions tailored to the worker and their goal, as well as the activities expected of other members of the support group including the employer, insurer, nominated treating doctor, treatment providers, and workplace rehabilitation provider (if applicable).

The IMP should consider:

• the return to work strategy (including use of SIRA-funded support programs under section 53 of the 1998 Act, if applicable - see Insurer guidance GNs 7.1 to 7.7 for more information on SIRA funded programs)
• rehabilitation
• treatment, and
• claims management.

Insurers should adopt a holistic approach. To ensure the success of the IMP, they should negotiate and agree to actions with each responsible party.

The insurer must also keep the employer informed of any significant steps taken, or proposed to be taken, under the IMP (section 45(5) of the 1998 Act).

Review schedule

The insurer should review the IMP periodically to ensure that it remains relevant to the worker’s circumstances.

Depending on the activities included in the plan, review dates may be either specific dates to coincide with particular events, or they may be more general timeframes.

When to review the injury management plan

The IMP is to be reviewed in accordance with the review dates specified within the plan (either specific dates or timeframes).

Significant events may include:

• approval of new treatment
• surgery
• a significant change in capacity (for example, from having work capacity to no capacity or vice versa)
• change in case manager or nominated treating doctor
• change in goal (for example, if employment ceases).

A review of the IMP may not result in a revised plan being issued. Insurers should make a file note when a new plan is not required.

Employer's obligations

An employer must participate and cooperate in the establishment of an IMP and comply with any obligations imposed under the plan (section 46 of the 1998 Act).

Employers have an obligation to provide suitable work to a worker following a work-related injury. The suitable work may be part- or full-time, and so far as reasonably practicable, should be in the pre-injury role or at an equivalent level.

This obligation does not apply if:

• it is not reasonably practicable, or
• the worker has voluntarily left that employment after the injury happened, or
• the employer has terminated the worker’s employment after the injury happened for a reason other than the worker’s injury or incapacity.

Worker's obligations

An injured worker who has a current work capacity must make reasonable efforts to return to work in suitable employment or pre-injury employment (section 48 of the 1998 Act).

If a worker unreasonably fails to comply with any of his/her obligations under section 48, payments of weekly compensation may be suspended, subject to the insurer giving written notice to the worker of an intention to stop making payments and advising the worker that payments will not resume until the worker complies with the notice (section 48A of the 1998 Act).

If weekly payments later resume (because the worker has complied), the worker forfeits any weekly compensation that would otherwise have been made during the period of suspension (section 48A(5) of the 1998 Act).