Claims management other

Overview

Before closing a claim, insurers should ensure that all activities have been completed and relevant stakeholders (including service providers) have been notified that the claim is to be closed.

This guidance considers the circumstances when an insurer may close a claim, and the importance of clear communication with all relevant stakeholders regarding the reasons for and the implications of the closure.

Closure of the claim

Claims can be closed for different reasons. The most common reason is that the worker has successfully recovered and returned to work. Other reasons claims are closed include:

• the worker and insurer have agreed to commute the claim
• the worker has reached pension age (some workers will retain an entitlement to medical expenses)
• the worker has recovered damages in respect of the injury
• the worker has died (whether due to the work-related injury or a non work-related condition) and all entitlements under the workers compensation Acts have been paid
• the worker ceases to be entitled to compensation under the Acts.

The Standard of practice S30. Closing a claim outlines SIRAs expectations for what the insurer should do prior to finalising a claim.

Worker has returned to work with no ongoing treatment

Before closing a claim for a worker who has returned to pre-injury duties or other suitable employment, the insurer should monitor the circumstances for a reasonable period of time to confirm that the return to work is sustainable.

What is a reasonable period of time will vary for each worker and the individual circumstances of the claim.

Insurers are encouraged to speak to the worker, treating professionals and the employer when forming their view around closing the claim.

Claim in error

When closing a claim where the claim is in error (for example, a duplicate claim or one entered against the wrong policy), the insurer should clearly record on the file the reason for the closure.

The insurer should also consider whether the worker, employer or anyone else needs to be informed of the reasons for the closure (this depends on the facts and circumstances of the claim).

Communication with the worker

The insurer should contact the worker to discuss the proposed closure of the claim. The communication may include:

• the reasons for closure, for example:
  • they have successfully maintained a return to pre-injury duties and are no longer having any treatment
  • their entitlement to medical benefits under section 59A of the Workers Compensation Act 1987 (1987 Act) has expired

• confirmation that the worker is no longer accessing services provided by workplace rehabilitation providers
• that any injury management or return to work plans are no longer in effect
• requesting the submission of any outstanding reimbursements or invoices
• advising the worker what to do should they require further treatment.

The insurer should give the worker the opportunity to ask any questions or raise any concerns and should address these.

The insurer should also advise the worker that the closure of the claim will be confirmed in writing (see Standard of practice S30. Closing a claim for the expectations regarding what information should be confirmed in writing).

Communication with the employer

Where relevant, the insurer should contact the employer to discuss the proposed closure of the claim including:

• the reasons for the closure
• that services such as those provided by a workplace rehabilitation provider will no longer be provided
• that any injury management or return to work plans are no longer in effect
• explain any limits to compensation which may be applicable for the worker
• request the submission of any outstanding reimbursements or invoices.

The insurer should give the employer the opportunity to ask any questions or raise any concerns and should address these.

The insurer should also advise the employer that the worker has been consulted and the closure of the claim will be confirmed in writing to both the worker and employer (see Standard of practice S30. Closing a claim for the expectations regarding what information should be confirmed in writing).

Note: For older claims, it is not uncommon for employers to no longer trade/be contactable. Insurers should exercise their judgement when determining the nature of their contact, if any, with employers.

Communication with treatment providers

The insurer should contact the current service providers to:

• advise that the worker’s claim is being closed and confirm that the worker no longer requires any treatment or other services
• request the submission of any outstanding accounts.

Written advice to the worker and employer to confirm claim closure

The insurer is responsible for ensuring that any written communication is correct and tailored to the individual worker and employer’s circumstances.