S32. Managing claims during the COVID-19 pandemic

S32.1

(Initial contact)

Following notification of an injury where the worker has a diagnosis of COVID-19, the insurer is to proactively contact all parties as soon as possible to discuss:

• the individual circumstances of the worker
• the health needs of the worker
• any potential barriers to recovery and return to work, and what options are available to the worker
• commence injury management planning, where appropriate (the injury is likely to be a significant injury).

Evidence on claim file

S32.2

(Applying the presumption)

For each claim notified for COVID-19, the insurer is to:

• ascertain whether the worker is in ‘prescribed employment’ and whether the presumption applies
• confirm with the worker what is required to establish they have contracted COVID-19 for the purposes of the legislation.

If further information is required to determine liability (including whether the presumption applies, or where the presumption doesn’t apply but where there is a high risk of exposure), the insurer is to:

• explain to the worker and employer what further information is required to determine liability, and
• provisionally accept liability and commence provisional payments without delay.

Note: If the insurer has a reasonable excuse for not starting provisional weekly payments in accordance with Part 2.1 of the Workers Compensation Guidelines, this is to be clearly documented on the claim file.

Evidence on claim file

S32.3

(Full liability decision)

Insurers are to:

• take proactive steps to obtain further information if required
• make a decision on full liability for a claim made by a worker with a confirmed diagnosis of COVID-19 at the earliest possible opportunity and as soon as relevant information is available
• notify the worker and the employer of the decision and the evidence relied upon to support that decision.

Note: An insurer is not prevented from accepting liability before the end of the provisional liability period (section 278 of the 1998 Act).

Evidence on claim file

Liability determined within 21 days of a claim being made, or before the end of the provisional period (whichever is the later)

S32.4

(JobKeeper Payment scheme)

Insurers are to determine the impact, if any, to weekly payments as a result of the JobKeeper Payment scheme.

The insurer is required to:

• contact the employer to determine whether they have applied for the JobKeeper payment for the worker
• maintain contact with the worker and the employer to stay informed about whether a worker commences, is no longer entitled, or ceases to receive the JobKeeper payment
• provide information to the worker about the impact of JobKeeper payments on their weekly payments. This information may be via written notification or fact sheets, and is to include where to obtain more information about the JobKeeper Payment scheme, changes to the worker’s weekly payments, the effect of the cessation of the JobKeeper payment on their weekly payments and who to contact for further information (including the IRO).

Note: The employer’s eligibility to claim the JobKeeper payment on behalf of their workers is determined by the Australian Tax Office. Changes in work capacity may affect a worker’s eligibility for the JobKeeper payment. Insurers will need to prepare workers for changes in earnings once JobKeeper payments cease.

Evidence on claim file

Information provided to the worker and employer within 5 working days of changes to weekly payments due to JobKeeper; or as soon as reasonably practicable

S32.5

(Weekly payments)

Insurers are to ensure that workers impacted by the COVID-19 pandemic continue to receive weekly payment entitlements without delay or interruption.

The insurer is to inform the worker that certificates of capacity:

• may be obtained for periods of longer than 28 days where 'special reasons' exist, and
• may be obtained from their treating physiotherapist or psychologist (applies to second and subsequent certificates only from 17 April 2020 for 12 months).

Note: SIRA would consider the COVID-19 pandemic to be a 'special reason' for the purposes of section 44B(4) of the 1987 Act.

S32.6

(Weekly payments in advance)

The insurer can, if appropriate, use discretion to agree to payment of weekly payment entitlements in advance (up to six weeks), as long as:

• the worker has a current certificate of capacity for the period in advance, and
• the worker’s capacity is not likely to change within that period, and
• the worker agrees to receive payment in advance.

The insurer is to consider the impact of JobKeeper payments and whether this would impact the amount of weekly payments.

S32.7

(Treatment)

S32.8

(Recovery at work support)

When an insurer becomes aware of a worker’s ability to maintain suitable work is affected by the COVID-19 pandemic, the insurer is to, where appropriate, proactively contact the worker and employer to:

• identify and address barriers to return to work, including options for flexible work
• facilitate engagement with appropriate community, rehabilitation and education services to encourage recovery
• explain what SIRA funded programs may be available to support return to work.

S32.9

(Independent consultations, work capacity assessments)

When scheduling an independent assessment (including an injury management consultant service, independent consultant service, or work capacity assessment appointment), the insurer is to:

• consider whether the issue can be resolved through further contact with the nominated treating doctor, treating specialist or allied health practitioner/s, and/or whether the appointment/service can be postponed until a later date
• consider the most suitable option for the appointment/service, including scheduling the appointment/service via video conferencing (where appropriate) or alternatively telephone (only where permissible)
• where a face-to-face examination is required, the insurer is to ensure appropriate travel arrangements have been made and agreed with the worker, including informing the worker that reasonable travel costs will be met by the insurer
• keep the employer informed regarding any upcoming examination or assessment and outcomes.

S32.10

(Independent Medical Examinations and assessments of permanent impairment)

When scheduling an Independent Medical Examination (IME) for a worker, the insurer is to:

• consider the need for the examination including whether further information can be obtained from the nominated treating doctor or specialist in the first instance, and /or whether the examination can be postponed until a later date
• consider the urgency of the matter, ensuring those workers whose entitlements may be impacted, such as matters where an assessment of permanent impairment is required for threshold purposes, are expedited
• consider the appropriate method of assessment, and whether a video-consultation is appropriate, or whether a face-to-face examination is required
• where a face-to-face examination is required, ensure appropriate travel arrangements have been made and agreed with the worker, including informing the worker that reasonable travel costs will be met by the insurer
• keep the employer informed regarding any upcoming Independent Medical Examinations and outcomes.

In circumstances where an IME has been delayed or postponed due to the COVID-19 pandemic, and a worker’s entitlements will be impacted, the insurer is to:

• contact the worker to explain the delay and the impact to the worker’s entitlements
• inform the worker about what options they may have and who they can contact for assistance (including the IRO).

Note: In some circumstances, the insurer will need to give notice in accordance with section 78 of the 1998 Act.

This standard applies to all claims during the COVID-19 pandemic from 26 June 2020.

Note: S32.1, 32.2, and 32.3 apply only to claims made for COVID-19 (i.e. the worker has been diagnosed with COVID-19).