Commencement date: 26 June 2020

View the previous Standards of Practice December 2018.

View the previous Standards of Practice October 2019.

About the standards

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.

Context

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, in accordance with section 23 of the State Insurance and Care Governance Act 2015.

SIRA has developed the Standards of practice: Expectations for insurer claims administration and conduct (Standards) after undertaking a comprehensive review of the workers compensation claims handling framework in NSW.

These Standards are supported by streamlined and consolidated Workers compensation guidelines (Guidelines). Together, the Standards and revised Guidelines set clear, consistent, accessible and enforceable expectations that will guide insurer conduct and claims management.

The Standards and Guidelines are part of SIRA's regulatory framework, which also includes the:

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 have impacted on the worker's claims experience. They may also seek to provide clarity where confusion or inconsistency among insurers have led 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 guide all claims management activity 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
  • timeliness and efficiency.

Application

The Standards within this document form the claims administration manual, for the purposes of section 192A of the 1987 Act.

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, SIRA encourages all insurers operating in the NSW workers compensation system to adopt the overarching claims management principles and any relevant Standard .

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.

The 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 and explain the rationale for each Standard is included in the on-line claims management guide.

Words used in the Standards of Practice have the same meaning as the words contained in the NSW workers compensation legislation.

Commencement

The overarching claims management principles and standard principles 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.

Directions to comply with these Standards, including the expectations and benchmarks, 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 licence issued under the Act.

SIRA may issue a Direction to insurer(s) to comply with individual Standards and/or all of the Standards.

New COVID-19 related Standard of practice

A new Standard of practice has been developed on the management of claims during the COVID-19 pandemic. It aims to set expectations for insurers about the handling of COVID-19 workers compensation claims and claims handling practices more generally throughout the period of the pandemic. Specifically, it is designed to:

  • clarify expectations regarding insurer decision making and determination of weekly payment entitlements to promote transparency and consistency, and provide certainty for impacted workers
  • reduce barriers and ensure workers are fully informed of supports and options available to them
  • support workers through their recovery and return to work

Standard of practice 32 will apply to insurers during the COVID-19 pandemic period. It will commence from 26 June 2020, and will be in effect for 12 months unless SIRA amends, revokes or replaces the Standards earlier.

Given the unprecedented nature of COVID-19 and the uncertainty about how the pandemic may unfold, SIRA will closely monitor the management of COVID-19 related claims and will consult on the need to further refine this Standard if appropriate.

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