S3. Initial liability decisions – general, provisional, reasonable excuse or full liability

Commencement date: 21 October 2019

Making initial liability decisions promptly, in consultation with key stakeholders and based on all available evidence will ensure that workers and employers can focus on recovery and return to work.

Principle

Liability decisions will be informed by careful consideration of all available information and proactive consultation with the worker and employer.

ExpectationsBenchmarks

S3.1

(General)

When determining liability, insurers are to obtain and consider all relevant information, consult with the worker and the employer, and make a decision at the earliest possible opportunity.

Evidence on claim file

S3.2

(Provisional liability)

If accepting provisional liability, the insurer is to provide the following information to the worker (in addition to the notice requirements in section 269 of the 1998 Act):

  • the worker’s pre-injury average weekly earnings (PIAWE) or average weekly earnings (AWE) and how that amount has been calculated
  • the amount of the weekly payment and how that amount has been calculated
  • who will pay the worker and when
  • what the worker can do if the worker disagrees with the amount or does not receive payment, and
  • what information the worker must provide (including when and to whom) to continue to be entitled to weekly payments.

Written notice provided to the worker within two working days after decision

S3.3

(Provisional liability)

If accepting provisional liability, the insurer is to provide the following information to the employer:

  • confirmation that weekly payments are to commence
  • the period for which provisional payments will continue
  • that the insurer will develop an injury management plan for the worker if required to do so by Chapter 3 of the 1998 Act, and
  • that the worker is entitled to make a claim for compensation and how that claim can be made.

Written notice provided to the employer within two working days after decision

S3.4

(Reasonable excuse)

If the insurer has a reasonable excuse not to commence provisional weekly payments, the insurer is to provide the following information to the worker (in addition to the notice requirements set out in section 268 of the 1998 Act) and to the employer:

  • how the excuse can be resolved
  • details about how further information can be sought from the insurer
  • that the worker can seek assistance from their union, a legal representative or the WIRO, and
  • that the worker has a right to seek an expedited assessment by the Workers Compensation Commission.

Written notice provided to the worker within two working days after decision

S3.5

(Full liability)

If accepting liability for a claim for weekly payments, the insurer is to provide the following information to the worker and the employer:

  • confirmation of the decision to accept liability
  • the worker’s pre-injury average weekly earnings (PIAWE) or average weekly earnings (AWE) and how that amount has been calculated
  • the amount of the weekly payments and how that amount has been calculated
  • who will pay the worker and when
  • what the worker can do if the worker disagrees with the amount or does not receive payment
  • that the insurer will develop an injury management plan for the worker if required to do so by Chapter 3 of the 1998 Act, and
  • what information the worker must provide (including when and to whom) to continue to be entitled to weekly payments.

Written notice provided to the worker and employer within two working days after decision

S3.6

(Full liability)

If an insurer requires a completed claim form to determine liability, they are to proactively request this from the worker and allow sufficient time for the worker to complete and submit the form.

Request at least four weeks before expiration of provisional period or upon exhaustion of provisional medical expenses

S3.7

(Full liability)

Upon request, the insurer is to provide the employer with information relevant to the liability decision, including the evidence considered and legislative provisions relied upon. In the event the information requested by the employer cannot be lawfully provided, the reasoning should be clearly documented on the claim file.

Written response provided within ten working days

Making initial liability decisions promptly, in consultation with key stakeholders and based on all available evidence will ensure that workers and employers can focus on recovery and return to work.

Liability decisions must be made in accordance with the legislation and informed by the careful consideration of all evidence. Key to the principles of fairness and transparency is the observation of procedural fairness and proactive consultation with the worker and employer.

When determining initial liability for an injury, insurers are to gather the relevant evidence, consult with key stakeholders (including the employer and worker) and ensure that the decision is made in a timely manner and communicated appropriately.

Insurers can accept liability for weekly benefits outright or they may accept liability on a provisional basis for a period of up to 12 weeks, having regard to the nature of injury and period of incapacity.

Alternatively, the insurer can delay making a liability decision on the claim by applying a reasonable excuse to the claim if they have sufficient reason for doing so. Reasons for when a 'reasonable excuse' are detailed in the Workers compensation guidelines.

Once the reasonable excuse has been resolved, the insurer can either provisionally accept within seven days or, fully accept, or deny liability for the claim within 21 days.

If a claim for weekly payments has been accepted provisionally, the insurer is required to determine the claim, by either accepting or disputing liability, before the end of the provisional period. This does not apply to claims finalised before the expiration of the provisional period.

Proactive communication with the worker and the employer is an integral part of sound decision-making. Decisions need to be made in a fair and transparent manner – this requires full and open communication between stakeholders.

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