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Making a Claim for Workers Compensation

Introduction

The following information sets out the procedures for making a claim for Workers Compensation at the University of South Australia and the management process.

Making a Claim

 Workers Compensation claim form can be downloaded.  

An employee who has suffered a work related injury or illness can make a claim for worker's compensation but must provide the following documents to assist in the determination of the claim.  

Fax 8302 1380 to OHSW & IM Services:

If the above documents are not submitted in a timely manner there may be a delay in the determination of your claim.

Where an employee or supervisor is uncertain as to the appropriate forms that should be completed, assistance can be provided from OHSW & IM Services .  OHSW & IM Services Administrative Officer  8302 01583, Rehabilitation Consultant 8302 1709 or WMC@unisa.edu.au

Claim Process

Upon receipt of a claim, OHSW & IM Services will forward the claim, incident report, WMC and any accounts to the Claims Manager.

OHSW & IM Services will provide written information to the claimant about the Workers Compensation process. Until the claim has been determined the claimant will utilise sick leave or other accrued leave entitlements.

The Claims Manager will ensure that necessary investigations and inquiries are made to determine the claim. This may involve ascertaining:

If further information is required, the Claims Manager will outline the reasons to the injured employee within 5 business days.

Claim Determination

Consistent with the requirements of Section 53(4) of the WR&C Act, the Claims Manager will endeavour to provide the employee with a determination of the claim within 10 business days of taking receipt of the employee’s claim.

Where a claim cannot be determined within 10 business days, the Claims Manager will communicate in writing to the employee, setting out the reasons why such determination has not been made. The Claims Manager will also advise the employee of his/her rights to a course of action to expedite a decision.

In determining a claim, a decision may be made to:

Where a determination is made of an employee’s claim, the Claims Manager will also advise the claimant in writing of the Workers Compensation Dispute Resolution Process. Refer also to the University OHSW & IM Workers Compensation and Rehabilitation Complaint Management Procedure.

Provisional Liability

Claims Management Responsibility

The Claims Manager is responsible for:

Rights of an Employee

If you sustain a work related injury / illness you have a right to:

Responsibilities of an Employee

Rights of the University

The University has a right to:

Responsibilities of Managers / Supervisors

Income Maintenance

Income maintenance refers to your normal wages and maintaining your income if you are absent from work due to a work injury / illness and not earning a salary for work. An employee who is totally incapacitated for work will receive compensation based on their average weekly earnings. The amount will be calculated as “Notional Weekly Earnings” or an amount the employee would expect to receive were they at work.

If an employee is partially incapacitated for work (i.e. undertaking reduced hours of work) they will receive salary for the hours worked and workers compensation weekly payments for the remainder or income maintenance.

Income maintenance is payable at 100% of the amount you were earning prior to being injured (pre-injury earnings for 13 weeks). At 13 weeks there is a reduction in payments to 90%, followed by a further reduction to 80% at 26 weeks.

Where the period of incapacity (whether total or partial incapacity) continues for more than 13 and 26 weeks the Claims Manager will conduct a review of the amount of weekly payments being paid.

Payment for Non Economic Loss

An employee who sustains a permanent disability may apply to the Claims Manager about their eligibility to receive a lump sum payment under Section 43 of the WR&C Act.

Other Compensable Expenses

An employee is entitled to be compensated for costs reasonably incurred as a result of their compensable disability in accordance with Section 32 of the WR&C Act.

The claims manager will reimburse medical and travel expenses but an employee should provide evidence to the satisfaction of the Claims Manager demonstrating the expenses were reasonably incurred.   Receipts for medication or an account from the provider of the medical service should be sent to the Claims Manager

The employee must obtain prior approval from Claims Manager or OHSW & IM Services for certain expenses. These include:

Medical Appointments

Where an employee is working modified hours with modified duties,, medical appointments should, where possible, be made outside of normal working hours.  This includes doctors / specialist consults, physiotherapy treatment or gym strengthening programs.  Otherwise appointments should be arranged for close to the beginning or end of a working day if an injured employee is working normal hours with modified duties.

Work Related Journey Accidents

Normal travel between work and home is not covered by workers compensation unless the employee can demonstrate ‘a real and substantial connection between the employment and the accident’. The fact that an employee has an accident whilst travelling to or from work is not in itself a sufficient connection.

Employees who are ‘on call’ or are undertaking journeys within a working day (eg from one campus to another) will usually be covered. Similarly, employees travelling away from home, including overnight absences will usually be covered for travel, provided that their manager has approved the journey.

Travel

If staff have an accident or illness whilst  working overseas, they should follow the Incident Reporting procedure within 12 hours so that assistance can be provided. Please note staff also must complete and  Overseas Business Travel form a Business Travel Request form (FS 87) and Line Managers should ensure that all staff travel is appropriately approved.

Psychological Claims

Claims for psychiatric or psychological illness may take longer to determine than those for physical injury. The reason for this is the specific criteria that need to be met before such a claim is compensable.

Employees who submit a claim for psychiatric or psychological illness may need to wait for their claim to be determined while a written report is sought from their treating practitioner. They may be referred to an independent medical expert for examination, and an independent claims investigator may also be appointed to seek further information that will assist the Claims Manager to determine the claim.

The Claims Manager will keep the claimant informed about the process and, if the claim is rejected, will explain to the claimant clearly why this has occurred together with the review rights if the claimant is not satisfied with the decision.

Claim Process

Upon receipt of an employee’s claim, the Claims Manager shall establish and maintain a file for each claim. Claim files will be stored in a secure location with access limited to those with the appropriate delegated authority.

Obtaining Medical Information

The Claims Manager will obtain relevant medical information about the nature of the injury / illness, possible prognosis, treatment plan and capacity for work. Regular requests for updated information should be maintained with treating practitioners during the life of the claim.

Confidentiality

Information about injured employees will be kept maintained at all times and made available only to those specifically authorised and communication on “a need to know basis” to enable effective management of rehabilitation.  Information shall only be shared with work colleagues with the consent of the injured employee.

Complaint Management Procedure

UniSA is committed to resolving  issues employees have about their Workers Compensation claim. An employee who is dissatisfied with a decision made about their Workers Compensation claim or rehabilitation should in the first instance discuss their concerns initially with their rehabilitation consultant, claims manager or OHSW & IM Services Manager.  If an employee believes their issue has still not been dealt with appropriately then a conference may be called with all parties present so the employee has the opportunity to raise their concerns. If the matter is not resolved through this process, the employee may wish to take the issue to the SA Workers Compensation Tribunal. The usual process following an application to the Tribunal is for a conciliation conference to be called. If no agreement can be reached the matter will proceed further (to an arbitration hearing or judicial determination).

Monitoring and Review

This procedure will be reviewed on a biennial basis or where there are changes to legislation.  A Self Audit  will be completed on Claim Files at least annually. The results of the Self Audit will be measured for improvement by identifying any issue(s). An Injury Management survey will be conducted annually through the “Tell-Us” automated program for injures staff.

Documents/Forms

 

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