We have received a WorkCover claim in Victoria!

NEWS CLAIMS - POINTS FOR CONSIDERATION

When dealing with a new claim that you suspect may not be work related, it's important to proceed with care and follow appropriate steps. Points for consideration are as follows-

1.     Gather information: Review all available information related to the claim, including the claim form, WorkCover medical certificate, and any supporting documents such as medical invoices. Assess the details provided by the employee and compare them with the circumstances surrounding the alleged workplace injury.

2.     Consult internal resources: Consult with relevant personnel within your organization, such as supervisors, managers, or colleagues who witnessed and/or have knowledge of the incident or that have a strong understanding of the employee's work-related activities. Gather any additional insights or evidence that can help inform your assessment without unnecessarily disclosing personal/private information about your employee.

3.     Document concerns: Document your concerns and observations regarding the claim. Be specific about the reasons you believe the claim may not be genuine. Include any discrepancies or inconsistencies in the provided information.

4.     Seek advice: If you have significant doubts about the claim's validity, it may be advisable to consult with experts in this area. They can provide guidance based on applicable laws and regulations and help you navigate the situation effectively.

5.     Notify the Managing WorkCover Agent/Insurer- If, after careful consideration and consulting with relevant parties, you still have substantial concerns about the claim, it is recommended to inform your Managing WorkCover Agent/Insurer. Provide them with a clear and detailed account of your reservations, along with supporting evidence or documentation. Your Worker may have access to your claim form and/or the documents you provide via Freedom of Information and on this basis sticking to the facts is very important.

6.     Cooperate with investigations-If the claim is being investigated by your WorkCover Agent/Insurer, fully cooperate, and provide any requested information or evidence. This will help ensure a thorough and fair assessment of the claim.

Why not highlight concerns for every claim and aim to have all claims investigated to ensure they are all genuine?

Some businesses take the view that having your Agent investigate every claim is the way to manage matters as this gives a company some chance of having claims rejected or greater certainty regarding the validity of a claim.

The philosophy of the system is focused on early intervention and rehabilitation. Unless there are strong grounds proving that the injury and workplace are not linked as required in law, having all claims investigated is a sure way of increasing your chances of paying a higher premium. The higher the claims cost for each claim the higher your premium is likely to be.

If grounds for possible rejection of a claim are not very strong, a claim is highly likely to be accepted and your claims costs may reflect additional investigation costs. These costs may include medical panel examiner costs, investigator costs, cost of GP reports, treating health provider reports and any costs linked to exploring the matter further.

Many factors influence premium. These include costs paid against a claim, industry rates, company performance rates and the estimated future costs of a claim. A claim in dispute is likely to attract both higher costs paid and higher estimated future costs.

Rejected claims are also likely to be accepted in many instances if a Claimant continues through an appeals process.

If your premium is concerning, the aim is to minimize all costs against a claim via proactive management and early intervention. All costs, both estimated and actual may have a rolling impact on your premium for many years to come.

In short, unless you have strong evidence disproving a claim for your Agent to consider, requesting an investigation, or highlighting concerns may increase claims costs in the long run.  If you are unsure, getting some advice in this regard is recommended.

It is to be noted that your Agent may identify grounds for investigation in line with their internal policies and procedures and decide on this course of action in any event.

Which claims should I consider highlighting to the Agent for possible investigation and what information may assist?

The following points raise some instances whereby an investigation may result in rejection of a claim-

·       The injury is not work related and/or not significantly contributed to by employment. If the injury/condition does not appear consistent with the duties, proof should be provided for the Agents consideration. This may include a position description, workplace footage of duties, information or footage disproving the alleged incident/accident, statements from witnesses that were present at the time of the alleged injury and anything else that may strengthen your case.

·       Knowledge and proof that the injury occurred elsewhere. This should be well documented and supported.

·       The injury has been claimed for in the past. In this instance, it is to be remembered that aggravation, recurrence, acceleration, or exacerbation etc. of a per-existing injury whether work-related or not may still be deemed as compensable resulting in an accepted further claim.

·       The claim was lodged as a result of performance counseling that was conducted in a compliant manner as per Fair Work guidelines.

·       The Claimant may be deemed a contractor or may not be considered a Worker.

The Agent cannot have a claim investigated if this step is not approved by their internal liability/legal team therefore the more information you can give them the better informed they will be when making this decision.

The Agents guidelines are very stringent and governed by WorkSafe. An Agent is obligated to comply with WorkSafe procedures, and they are audited against procedures risking fines and ultimately their Agents license if audit requirements are not met. If they decide not to proceed with an investigation it generally is because the evidence does not support this action.

What happens if a claim is rejected?

·       If a claim is rejected, a Worker may appeal by lodging a request for a Conciliation conference.  This is a free service.

·       At the time of this conference the parties are encouraged to settle this matter by a way of reaching an agreement. If a medical dispute is apparent the Conciliator may refer the case to a Medical Panel for a binding decision to be made.

·       If a dispute is circumstantial, meaning based on specifics that do not relate to a medical difference of opinion, the parties could not come to an agreement and/or the evidence does not support reinstatement of wage entitlements strongly enough the matter can be certified a Genuine Dispute. This means the decision made by the Agent remains in place.

·       A large percentage of matters that proceed due to a Worker appealing end up settling for a monetary figure pre-trial and the Victorian system has been overhauled to provide the Accident Compensation Conciliation Services the power to settle matters that do not resolve via Conciliation.

·       On the basis of the above, focusing on early intervention, return to work and resolution of a claim by assisting in the returning a Claimant to gainful employment is often the most effective way in rehabilitating your employee, minimizing your claims costs and in turn your premium.  The faster this is addressed the more promptly a claim is likely to resolve.

Disputing claims or attempting to do so should be reserved for cases whereby proof is strong. The checklist below lists some matters for consideration however is not limited to the particulars provided. As a general rule remember that return work obligations may also remain in place while a claim is held pending and are often advisable until an appeal outcome is determined where practicable and or required. Speak to your Agent to find out if this applies to your case.

 CLAIMS DISPUTE – POINTS FOR CONSIDERATION

-I do not believe the injury/condition happened as a result of work duties or that work duties contributed to this condition.

-The claim is for stress of a type that is not compensable- seek advice as needed.

 -I have proof by the way of statements from witnesses, legally acquired footage, a copy of the position description that doesn’t support injury mechanism and provides ample proof to suggest the injury is not work related.

 -The Claimant is not deemed a Worker and is a contractor and/or not an employee of our organization as defined in law. Your Agent has a checklist for this. Each case should be assessed on its merits.

 -The claim has been lodged as a result of performance counseling that was conducted in a compliant manner as per Fair Work guidelines and we can provide substantial proof in this regard.

-This Claimant has claimed for this condition previously. Keep in mind if the condition has worsened in any way, as a result of work duties, the claim is likely to be accepted.

-The injury/condition occurred as a result of misconduct an the matter was managed as per Fair Work guidelines. I have adequate proof of reasonable management action.

*Please note that the above is not an exhaustive list.