General overview

This section of the SIRA workers compensation claims management guide (claims management guide) explains the workers compensation claims journey in plain English.

It introduces the workers compensation claims process and includes information on the main aspects of a claim from who is covered, what injuries are covered and notifying the insurer of an injury, to insurer claims management, worker treatment, recovery and claim closure.

This section is ideal for workers, employers and stakeholders new to the workers compensation system. It also provides links to other information if the reader wishes to learn more about each topic.

Other sections in the claims management guide

• Insurer guidance is designed to provide insurers with guidance on a comprehensive range of claims management topics.
• Legislation and regulatory instruments contains relevant workers compensation legislation, regulation and guidelines issued by SIRA, in accordance with specific guideline-making powers contained in the Acts. The Standards of practice detail SIRA expectations for claims handling and conduct for insurers operating in the NSW workers compensation system.

Further information about the claims management guide can be found in About the guide.

Workers compensation

Workers compensation insurance provides support and assistance to workers to help them recover as soon as possible from a work-related injury/illness. This support can include (but is not limited to):

• weekly compensation payments while a worker is unable to work at their pre-injury capacity
• medical and hospital expenses
• domestic assistance
• new employment assistance
• education or training assistance, and
• a range of programs to help the worker recover at/return to work.

Compensation can also be payable upon death of a worker, compensation for permanent impairment and compensation for property damage.

Most employers in NSW are required to have a workers compensation policy to protect them from the costs of workers compensation claims (unless they are exempt).

An employer may be exempt if they:

• pay $7,500 or less in annual wages, and
• don't employ an apprentice or trainee, and
• are not a member of related businesses in a group for premium purposes, and
• are not involved in:
  • taxi driving
  • hire car driving
  • horse racing
  • professional boxing, wrestling or combat sports (as these industry groups are subject to the $0 exemption limit in the Workers compensation market practice and premium guidelines).

Information on insurance requirements can be found on the SIRA website. Claims made by workers with an exempt employer are managed through icare.

The insurer's role

The insurer is the main point of contact for a claim and is responsible for coordinating all aspects of the claim. The insurer works collaboratively with the worker, employer, nominated treating doctor and other providers to achieve the best possible recovery and return to work outcome. Their role includes managing and approving any support payments or services required.

icare acts for the Nominal Insurer, which is the insurer for most employers in NSW. Some employers either self-insure (fund and manage the claims of their workers directly) or use a specialised insurer for their industry. A list of licensed self and specialised insurers in NSW can be found on the SIRA website.

If a worker does not know who their employer’s insurer is, they can call the Independent Review Office (IRO) on 13 94 76 for assistance.

Employer support

Employers have a key role in assisting a worker’s recovery and return to work following injury. This includes an obligation for employers to provide work that is suitable and supports a worker’s needs during recovery.

In most cases, employers will also pay workers any weekly compensation entitlements through their payroll and maintain the employer/worker relationship throughout the recovery process.

Workers

The system is designed to achieve the best possible recovery and return to work outcomes for workers with a work-related injury/illness. Where workers are not able to fully recover and return to work, longer term support is available.

Workers need to provide certain information as part of their claim and have a number of obligations relating to participation in injury management and return to work processes.

Where to get help

Understanding the claims journey provides general information about the claims management process, and includes links to related content and resources – both within the claims management guide and externally.

Additional resources are also available, including:

• Have you been injured at work? - an online SIRA tool to help workers understand their weekly payments and entitlements at different stages of their claim.
• IRO - handles all worker enquiries and complaints regarding insurers. Contact IRO on 13 94 76.
• support from the worker's union or legal representative/s. Funding may be available for legal support through the Independent Legal Assistance and Review Service.
• SafeWork NSW inspectors - inspectors may visit a workplace where a complaint regarding employer provision of suitable work has been raised. Contact SafeWork NSW on 13 10 50.
• SIRA - regulates the NSW workers compensation system and related activities. We handle all employer and provider enquiries, and manage all complaints regarding employers and providers operating in the NSW workers compensation system. Contact us on 13 10 50.