Claims decisions

Insurers undertake investigations to determine the facts of a workers compensation claim. They may need to clarify:

• the nature and cause of the injury
• the circumstances of the injury

An insurer may also undertake investigations to identify recovery or common law potential.

Insurers should make reasonable attempts to verify information without referral to an external provider for an investigation. Insurers are expected to attempt to contact all relevant parties and obtain necessary information themselves.

Investigations may include:

• contact with the worker, employer, nominated treating doctor and other service providers
• requesting documents and records from these parties
• factual investigation
• independent medical examination for an objective medical opinion.

Factual investigation

Factual investigations use an investigation services provider to conduct an investigation to determine the likely factual circumstances in respect of a claim.

The investigation may involve an interview with the worker, employer and/or witnesses, as well as a physical inspection, and/or other external enquiries to check relevant details.

Surveillance

Surveillance refers to the monitoring and recording of activities and includes photography, video recording, direct observations and social media monitoring.

Insurers may use surveillance to verify worker claims, including their stated level of impairment or capacity to return to work. Surveillance may also be used when fraud is suspected.

Surveillance information can be used as evidence to dispute liability to pay compensation and may be admitted as evidence before the Personal Injury Commission (the Commission). The weight given to surveillance will depend on the circumstances of the claim, how the surveillance evidence was obtained, the nature of the surveillance itself and if there is any other supporting evidence.

If a worker has concerns about the use of surveillance in their claim, they can raise the matter directly with their insurer, union or with the Independent Review Office (WIRO) on 13 94 76.