Claims management other

Overview

Managing over-payments to workers in a fair and transparent manner contributes to the viability of the system and helps to preserve the relationship between the insurer and the worker.

Over-payments can occur for a range of reasons and the actions an insurer can take will depend on the reason for, and the amount of, the over-payment.

This guidance provides information for insurers when seeking to recover an over-payment from a worker.

Recovering over-payment with informed written consent

Recovery of over-payment due to insurer error

To seek recovery of an over-payment from the worker the insurer is expected to take the following steps:

• advise the worker of the details of the payment(s) and clearly describe the error and the impact to the worker
• where the insurer negotiates a repayment arrangement with the worker, the insurer should demonstrate they have considered the individual circumstances of the worker including potential financial hardship
• obtain the worker’s informed consent for repayment.

See Standard of practice S23. Recovery of overpayments due to insurer error.

Worker consent

Without the informed, written consent of the worker, or an order from the Personal Injury Commission (Commission) or an order of a court of competent jurisdiction, the insurer has no power/authority to garnish workers compensation benefits.

If the insurer is unsuccessful in obtaining agreement from the worker, the insurer may be able to pursue one of the following options.

Over-payments not related to fraud

Under certain circumstances the insurer may apply to the Commission for an order to adjust the weekly payments of compensation to a worker.

An insurer may take this action if the over-payment relates to a refund of weekly payments paid after a return to work or those circumstances outlined in section 58 of the Workers Compensation Act 1987 (1987 Act).

The insurer should ensure they have sufficient evidence, consider whether the matter is worthwhile pursuing (commercially viable) and the individual circumstances of the worker.

Over-payments related to fraud or a false claim

An insurer may choose to refer a matter to SIRA if they have sufficient evidence to support that a worker/person has made a false claim as defined in section 235C of the Workplace Injury Management and Workers Compensation Act 1998 (1998 Act), or that they have committed fraud against the workers compensation scheme in accordance with section 235A of the 1998 Act.

An insurer may decide to refer a matter to SIRA after taking the following into consideration:

• the availability and accuracy of evidence
• the amount of the over-payment
• any reputational risk to the workers compensation scheme
• any communication had with SIRA regarding the merits of pursuing the matter.

Review of quality assurance systems

Insurers should have processes in place to minimise the risk of over-payment or duplication of payments to workers. This includes having appropriate quality assurance practices in place and suitable training for staff.

Regardless of the action taken by an insurer on the individual claim, a review of an insurer’s over-payment prevention systems should occur once an over-payment has been identified, in order to prevent future claim over-payments.