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Workers' Compensation - Injury Reporting and Claims Process

Aim
The aim of managing a workers' compensation claim is to:

rehabilitate the sick or injured worker back into the workforce as soon as possible; and
ensure that the sick or injured worker (or his or her dependants) is compensated for lost wages, and medical and other rehabilitation costs.

Roles and responsibilities

Government agencies

Government agencies are responsible for the ongoing management of a workers' compensation claim. This responsibility cannot be handed over to another entity. Rehabilitation providers may be engaged to assist with the management of certain cases, and the Fund Administration Agent, JLT Public Sector (JLT), may provide rehabilitation or administrative advice, but responsibility for decisions about, and management of, the case remains with the agency.

Similarly, agencies should maintain direct contact with an injured employee and not leave this to the rehabilitation provider or JLT. In addition, it is important that the employee's supervisor and manager also keep in touch. The injured employee should be kept informed of all future processes, understand their purpose, and be provided with the opportunity to ask questions.

Government agencies' responsibilities also include:

ensuring that they have an approved injury management program in place and operate in accordance with it;

appointing an Injury Management Coordinator when an injured worker suffers an injury that is likely to result in total or partial incapacity for more than 5 working days, and requires (or is likely to require) ongoing medical treatment;

ensuring that all employees have ready access to:

a summary of the provisions under the Workers Rehabilitation and Compensation Act 1988 (this summary must also be prominently displayed in every workplace); and

the employer's injury management program;

keeping records of all injuries notified by their workers (regardless of whether there is a formal claim for compensation);

notifying JLT within 3 working days (the way that JLT is to be notified should be set out in the agency's injury management program):
- of becoming aware that a worker has suffered a workplace injury that results in, or is likely to result in, the worker suffering an incapacity for work; or
- of becoming aware that a worker has suffered a workplace injury that is required to be reported under the agency's injury management program; and
- of receiving a claim for compensation from a worker;

reporting serious and dangerous incidents to the regulator, in accordance with section 38 of the Work Health and Safety Act 2012;

completing the employer's report section of a claim for compensation form, ensuring that the worker has completed the worker's report section and provided a fully completed Workers Compensation Medical Certificate, and sending the duly authorised claim form (and medical certificate) to JLT within 5 working days of its receipt;

deciding whether to dispute liability for an injury or a medical or other expense, and if a decision is made to dispute the claim, serving (or requesting in writing that JLT serve) a formal notice of dispute to the worker (or his or her dependants) and, where applicable, the Workers Rehabilitation and Compensation Tribunal or service provider, in the form and within the timeframe specified in the Workers Rehabilitation and Compensation Act 1988;

appointing Workplace Rehabilitation Providers (WRP), verifying invoices received from the WRP for payment and performance management of providers;

if the injured worker is likely to be incapacitated for longer than 5 days but less than 28 calendar days, a return-to-work plan needs to be prepared, in consultation with the injured worker, his or her medical practitioner, the rehabilitation provider, the injured worker's supervisor and, if the employee desires, a union representative;

if the injured worker is likely to be incapacitated for longer than 28 days an injury management plan will be required (incapacity can either be total or partial or a combination of the two);

paying weekly income replacement payments and seeking reimbursement from JLT. Duly authorised requests for reimbursement should be lodged via the automated wage reimbursement system. It is the agency's responsibility to ensure that the weekly income replacement payment amounts for which the agency is seeking reimbursement are calculated in accordance with the payment amounts prescribed by the Workers Rehabilitation and Compensation Act 1988 (eg are appropriately adjusted for Award changes, 'step down' requirements, paid holidays etc). Any additional amounts paid by an agency are the direct responsibility of the agency - not the Tasmanian Risk Management Fund. JLT has the authority to refuse incorrect or incomplete claims for reimbursement. It is also important that JLT is advised of weekly income replacement payments made during the excess period (and which are therefore not reimbursable by JLT), to ensure that its records are complete;

authorising WRP invoices and forwarding them to JLT for payment.

providing JLT with written directions on the administration of workers' compensation claims.

setting or adjusting case estimates in accordance with the Guidelines for Setting Workers Compensation Estimates; and

ensuring that the Office of the Solicitor-General is furnished with all necessary instructions and assistance when seeking legal advice.

In addition, the employer must:

keep the injured worker's pre-injury position open for 12 months, unless it can be shown that this is not reasonably practical, or there is no longer any reason for that position to exist; and

if practical, provide suitable alternative duties for a worker for up to 12 months following an injury.

A checklist that can be used and adapted by agencies to help manage their workers' compensation claims can be found under Tools.

Fund Administration Agent

(see JLT Public Sector (JLT))

General Practitioner

The general practitioner (GP) is the primary medical carer and is generally responsible for coordinating specialist medical care. The treating doctor is obliged to provide the employer, JLT, and other health service providers with information regarding the injured worker if requested.
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Injury Management Coordinator

An IMC is responsible for coordinating and overseeing the entire injury management process. An IMC is to be appointed when an injured worker suffers an injury that is likely to result in total or partial incapacity for more than five working days and requires (or is likely to require) ongoing medical treatment. The role of the IMC is to coordinate and oversee the entire injury management process, including medical treatment, return to work and all aspects of Return to Work Plans and Injury Management Plans.

JLT Public Sector (JLT)

JLT is the Fund Administration Agent. Its main responsibilities are to:

administer workers' compensation claims. This includes reimbursing agencies the cost of wages; paying medical and other expenses; meeting regularly with agencies to review claims; and, at the written direction of agencies: investigating liability; managing disputes; and seeking legal advice from the Office of the Solicitor-General;

review all claim and payment documentation to make sure that it is complete, accurate and appropriate (ie that it has been prepared in accordance with the requirements/prescriptions of the Workers Rehabilitation and Compensation Act 1988). JLT has the authority to refuse incomplete or incorrect claims for payment;

provide rehabilitation and claims management (but not legal) advice to agencies, either proactively or in response to a request by agencies (but it is the responsibility of agencies to decide whether to accept or reject the advice);

provide regular reports to agencies on the progress of, and actual and outstanding costs associated with, each claim; and

broker the purchase of separate workers' compensation cover, if required, for agency employees residing interstate or overseas.

Medical Panel

The Workers Rehabilitation and Compensation Tribunal may refer medical questions to a medical panel if there are conflicting medical opinions. The panel is made up of two or three medical practitioners, including a general practitioner (GP) and an appropriate specialist, none of whom will have previously been involved in the treatment of the injured worker.

The decision of the medical panel, in respect of the medical question, is final and binding on all parties.

Office of the Solicitor-General

The Office of the Solicitor-General is exclusively responsible for providing legal advice on claims, and provides legal representation in various courts and tribunals as required.

The Office of the Solicitor-General will arrange for external legal assistance if the Office of the Solicitor-General determines, in consultation with the agency, that it is required.

Rehabilitation Provider

Agencies may choose to appoint a rehabilitation provider to assist in the management of certain workers' compensation cases. Rehabilitation providers are to be selected from the TRMF Workplace Rehabilitation Provider Panel. The role of the rehabilitation provider is to, in consultation with the employer, medical practitioner and injured worker:

assess the needs of the injured worker and the workplace requirements;

identify and coordinate any health and vocational services, and workplace modifications, needed to return the injured worker to work;
providing quality reports within specified timeframes;
maintaining a robust, secure and confidential records management systems;
complying with invoice requirements; and
monitor the return-to-work process and ensure that goals remain appropriate and achievable.

Return to Work Coordinator

The Return to Work Coordinator provides the injured worker with workplace based support and assistance throughout the rehabilitation and return to work process.

Tasmanian Risk Management Fund

The Tasmanian Risk Management Fund was established to provide a whole-of-government approach to funding and managing specific, identified, insurable liabilities of inner-Budget agencies.

All workers' compensation claim costs (less the excess selected by the agency each year) are funded through the Tasmanian Risk Management Fund. These costs are ultimately recovered from agencies through annual contributions.

Worker

Workers are responsible for:

reporting any work-related injury or disease to their supervisor as soon as practicable, regardless of whether or not the worker intends to claim workers' compensation;

obtaining a Workers' Compensation Medical Certificate from an accredited medical practitioner;

completing a Worker's Claim for Compensation form and providing it (and the Workers' Compensation Medical Certificate) to their employer. All claims should be lodged within six months of the date of injury;

in the event of an extended absence from work, ensuring that a new Workers' Compensation Medical Certificate is provided to their employer before (or just after) their previous Certificate expires. Payment of benefits depends on this requirement being met;

participating in a rehabilitation program or undertaking suitable alternative duties. Weekly benefits are dependant on the worker's cooperation in this regard;

making themselves available for a medical examination by a doctor provided and paid for by the employer, at any reasonable time and place, and undertake any recommended treatment. Failure to do so will result in the suspension of weekly payments until the matter is determined by the Workers Rehabilitation and Compensation Tribunal. An exception is if the worker refuses surgery. In this case, weekly payments continue until the Workers Rehabilitation and Compensation Tribunal determines the matter; and

obtaining a clearance certificate from their medical practitioner before returning to work.

Workers have the right to:

select their own treating doctor and have a say in the selection of their rehabilitation provider;

be involved in the management of their injury, including being consulted on when and how they return to work;

seek payment of medical expenses (up to a total of $5 000) before liability for the injury that has been accepted;

access the Workers Rehabilitation and Compensation Tribunal for the early resolution of any disputes that may arise; and

under certain conditions, access damages in addition to the benefits provided under the Workers Rehabilitation and Compensation Act 1988, by undertaking a common law action.

WorkSafe Tasmania

WorkSafe Tasmania is responsible for administering the Workers Rehabilitation and Compensation Act 1988. It also investigates serious accidents and incidents as reported by employers in accordance with the requirements of the Work Health and Safety Act 2012. WorkSafe is currently a division in the Department of Justice.

The Workers Rehabilitation and Compensation Tribunal

The Workers Rehabilitation and Compensation Tribunal hears all workers compensation disputes. It has the status of a court of law. Its findings (on matters of law only) can be appealed to the Supreme Court of Tasmania. Information on the practices and procedures of the Tribunal are provided in the Workers Rehabilitation and Compensation Regulations 2011.

Process for reporting an incident and making a claim

The steps involved in reporting an injury, and making and managing a workers' compensation claim, are summarised below, and detailed in the following table. Agencies must not lose sight of the aim of the claim management process, which is to ensure that the injured worker is successfully rehabilitated back into the workplace as soon as possible. Agencies should actively manage all claims with this aim in mind.

1. Notification of an injury
2. Lodgement of a workers' compensation claim by injured worker
3. Receipt of a workers' compensation claim by employer
4. Claim forwarded, by employer, to JLT
5. Acknowledgement of claim, and allocation of claim number, by JLT
6. Copy of claim forwarded to WorkCover Tasmania Board, by JLT
7. Payment of weekly income replacement payments
8. Disputing liability for a claim
9. Return-to-work plan
10. Ongoing claim management
11. Finalising a claim

Step	Action	When	Further information
1.	Notification of injury	As soon as practicable after incurring the injury (and preferably on the same day)	Employees should report all injuries to their supervisor, or someone else in authority, either verbally or in writing (using the agency's incident/accident report form, if provided). The information provided in the report should include: the name and address of the person injured the nature and cause of the injury; and the date and time it was incurred. A formal notice of injury should be lodged regardless of whether the employee intends to make a claim for worker's compensation (note that a person may not be entitled to compensation later if a notice of injury was not lodged at the time of the incident). Agencies should notify JLT within 3 working days of becoming aware that a worker has suffered a workplace injury that: results in, or is likely to result in, the worker suffering an incapacity for work, OR is required to be reported under the agency's injury management program. Agencies should keep a record of all injuries incurred in the workplace. NOTE: In accordance with section 38 of the Work Health and Safety Act 2012, the regulator must be immediately advised of all incidents resulting in death or serious injury or illness (see section 36 for what constitutes a serious injury or illness), or a dangerous incident (see section 37 for what constitutes a dangerous incident), followed by a written report within 48 hours if required by the regulator. In accordance with section 39 of the Work Health and Safety Act 2012, the employer must ensure so far as is reasonably practicable, that the site is not disturbed until an inspector arrives (or earlier if the inspector directs), unless this is necessary to assist an injured person for example.
2.	Lodgement of a workers' compensation claim by injured worker	As soon as practicable but no later than 6 months after the injury was incurred	Worker's Claim for Compensation forms are available from nominated areas within agencies (usually Human Resources). A sample form is provided on this website for information only. A Workers' Compensation Medical Certificate must be lodged with the claim form. A claim for compensation is only deemed to have been made, and benefits be payable, when both documents have been provided to the employer. The injured employee should complete the worker's report section only. The employee should retain the brown copy of the form.
3.	Receipt of a workers' compensation claim form by the employer	Upon receipt of the claim (or before if the employer is aware that one is to be lodged)	Upon receipt of a workers' compensation claim, agencies should: notify JLT within 3 working days; first consider whether the injury or disease is work-related. It is advisable to consult JLT if there are any doubts about this. It may be necessary to: investigate the claim (JLT would normally be responsible for engaging loss assessors to undertake this); and/or seek independent medical advice (normally arranged by JLT). If the agency decides that it is going to dispute liability, it should begin to implement formal dispute procedures (see Step 8). regardless of the decision made above, the agency should also immediately start to consider (and implement) the steps required to return the worker quickly, safely and durably to work and finalise the claim. Early intervention and proactive management are critical in achieving return-to-work goals. In consultation with the treating general practitioner, this may include: preparing a return-to-work plan (see Step 9); engaging a rehabilitation provider; and considering alternative duties.
4.	Employer to forward claim to JLT	Within 5 days of receipt of claim by employer	The government agency should complete the employer's report section of the claim form and forward it, and the Workers Compensation Medical Certificate, to JLT within 5 working days of its receipt. The agency should retain the black copy of the form.
5.	JLT to allocate a claim number and acknowledge receipt of the claim	On the day that a claim is received	JLT will acknowledge receipt of a claim within 3 working days. The acknowledgement will include advice of the claim number allocated to the claim. This claim number must be quoted in all future correspondence concerning the claim, including when submitting certificates and accounts to JLT.
6.	JLT to forward a copy of the claim to WorkCover Tasmania Board	Within 5 days of receipt of claim by JLT	JLT will forward a copy of the claim to the WorkCover Tasmania Board. JLT retains the purple copy of the form.
7.	Payment of weekly income replacement payments	On the next normal payday or within 14 days following receipt of a claim	Income replacement payments are payable: on the next normal payday; or no later than 14 days after, receipt of a claim (together with a Workers' Compensation Medical Certificate) by the agency, regardless of whether the agency intends to dispute liability for the injury or disease (although if an agency does intend to dispute a claim, it is not obliged to meet medical or other costs associated with the claim). Weekly payments are payable from the date of incapacity or 14 days before the claim was provided to the employer, whichever is later. It is advisable for agencies to check with JLT regarding the calculation of weekly income replacement payments. The Workers Rehabilitation and Compensation Act 1988 requirements regarding paid holidays etc, are quite complex. Ongoing payments are subject to the receipt of periodic medical certificates. These should be forwarded to JLT upon receipt by the agency. After a period of 26 weeks, weekly payments reduce to: 90% of the normal weekly payment for weeks 27 to 78, inclusive; and 80% of the normal weekly payment, thereafter, for up to a maximum of 9 years. This extends to 12 years for workers left with a permanent whole person impairment (WPI) of between 15% and 19%; to 20 years with a WPI between 20% and 29% and to age of retirement for WPI of 30% or more. Weekly payments cease if the Workers Rehabilitation and Compensation Tribunal finds that the employer has made a "reasonably arguable case" concerning liability. The cost of the weekly income replacement payments is reimbursed to the agency by JLT. Agencies should lodge a standard reimbursement form to JLT each fortnight. JLT will reimburse agencies within 10 working days of receipt of the form. Note that the TRMF will only cover agencies for payments made in accordance with the requirements of the Workers Rehabilitation and Compensation Act 1988. Agencies are directly responsible for any additional amounts paid.
8.	Disputing liability for an injury or disease	Within 84 days of receipt of a claim (NB: Medical expenses and payments to dependants must be disputed within 28 days. See Other Benefits and Payments to Dependants for further information)	If an agency disputes liability for an injury or disease, the agency (or JLT acting on the agency's written instructions) must, within 84 days of receiving the claim: serve the injured worker with written notice that the agency disputes liability, providing details of the reasons for doing so; and refer the matter to the Workers Rehabilitation and Compensation Tribunal. It is important to note that the referral to the Tribunal must be accompanied by all evidentiary material upon which the employer intends to rely at the hearing. The Tribunal may disallow the introduction of evidentiary material after the referral has been lodged. The Chief Workers Rehabilitation and Compensation Commissioner or another Commissioner will determine whether the employer has made a "reasonably arguable case" and make an order regarding the continued payment of weekly income replacement and other benefits. If an agency does not dispute a claim within 84 days, it is deemed to have accepted liability for the claim. See Other Benefits for information on the processes and timeframes for disputing medical and other expenses. See Payments to Dependants for information on the processes and timeframes for disputing liability in relation to a claim made by the dependants of a deceased worker.
9.	Return-to-work plan	If a worker is likely to be incapacitated for more than 5 days but less than 28 days, a return-to-work plan must be prepared before the expiration of 5 days after the worker becomes incapacitated for more than 5 working days (but preferably consideration should be given to the steps required to return an injured worker to work as soon as the injury is notified) (NB: An injury management plan is required where a worker is likely to be incapacitated for 28 days or more)	Consideration should be given to the steps required to return an injured worker to work as soon as notification of the injury is received. The Workers Rehabilitation and Compensation Act 1988 requires that a formal return-to-work plan be prepared where a worker is likely to be incapacitated for more than 5 days but less than 28 days, a return-to-work plan must be prepared before the expiration of 5 days after the worker becomes incapacitated for more than 5 working days. The return-to-work plan should be prepared by the employer in consultation with the injured worker, his or her treating medical practitioner and the rehabilitation provider. The plan should be realistic and achievable. The objective of the plan is to ensure that the injured worker returns to work in a safe and timely manner. The return-to-work plan should include: the name of the injured worker; an estimate of the date that the injured worker should be fit to return to work; an offer of suitable duties; the steps to be taken to facilitate the worker's return to work. This may include re-training, workplace enhancements, a graduated return to work etc; and a statement of the long-term goal or aim of the plan. Ideally, the plan should be signed by both the employer and the worker. Copies of the plan should be provided to the worker, the treating doctor, and JLT. A clearance certificate should be obtained from the treating general practitioner before a worker returns to work.
10.	Ongoing claim management	Ongoing	Agencies should meet regularly with JLT and rehabilitation providers to review all open workers' compensation claims. The focus of the reviews should always be on finalising the claims as soon as possible. Issues that may be considered at the reviews include: the impact and effectiveness of treatment and whether the return-to-work plan needs to be modified; investigations (results or need for); independent medical reviews (results or need for); and payment of weekly benefits, ie ensuring that payments are stepped-down in accordance with the entitlements prescribed in the Workers Rehabilitation and Compensation Act 1988. Responsibility for carrying out agreed actions should be clearly assigned at the meeting. JLT provides agencies with regular reports to enable them to keep track of the progress, and actual and outstanding costs associated with each claim. Agencies should also keep in regular contact with the injured worker to ensure that he or she is kept informed of all future processes, understands their purpose, and is provided with the opportunity to ask questions.
11.	Finalising a claim		Medical requirements A clearance certificate must be obtained from the treating general practitioner before a worker returns to work. Administrative requirements When a claim is finalised, especially if there is no settlement, it is important to note all the circumstances that led to the finalisation of the claim, on the claimant's file. Agencies must advise JLT, in writing, that the claim is to be, or has been, finalised. Note that if an employee leaves the State Service, this does not stop his or her entitlement to compensation. Legal requirements The Office of the Solicitor-General must be consulted if a claim is to be settled or if a common law action is brought against the agency. Agencies should note that the TRMF will only reimburse agencies if the Office of the Solicitor-General considers that a settlement amount is reasonable. Agencies are directly responsible for any additional amounts paid. *Settling a claim:* Claims may be settled by agreement between the parties, after 2 years, if the injury is stable. *Common law actions: An injured worker may sue an agency for damages under common law only when the injury or disease results in a 20% or greater whole-person impairment. The claim may be settled if the agency is liable and an amount is agreed upon. A Deed of Release* must be obtained, if an action is settled, to prevent future actions arising from the same incident. When providing instructions to the Office of the Solicitor-General, the following documentation should be provided: the current file(s); and details of other claims made by the employee, including the date of the injury leading to the claim, the nature of the injury, and how the claim was settled.

Disputes
Any dispute between an employer and an injured worker may be referred to the Workers Rehabilitation and Compensation Tribunal for determination. This includes:

disputes as to the reasonableness or necessity of any medical or rehabilitation service;
reviewing settlements (within three months from the date of settlement). The Tribunal may set aside an agreement it deems to be inequitable, made under duress, or made by a party lacking the legal capacity to make it.

With the exception of disputes regarding liability (which are discussed under the Process for reporting an incident and making a claim heading above), conciliation is always the first stage of the dispute process. If an agreement is unable to be reached, the matter is referred to the full Tribunal for determination. The Tribunal may refer medical questions to a medical panel. Information on preparing for, and the procedures associated with, conciliation conferences and Tribunals are provided in A Guide to Workers Rehabilitation and Compensation in Tasmania.

Referring workers' compensation matters to the Office of the Solicitor General
Requests to the Office of the Soliciotr General (OSG) for legal advice on workers' compensation claims ought to be directed through JLT. If the Office of the SG is approached directly, JLT must be informed.

Where possible, the Office of the SG should be provided with specific instructions, for example, the application of a particular section of the Workers Rehabilitation and Compensation Act 1988 to a particular set of circumstances.

Matters that may be referred to the Office of the SG for advice include:

disputes regarding liability (section 81A);

termination or reduction of benefits (section 86 and section 88);

contributions or indemnity from third parties (section 134);

notice to bring action on (section 136);

common law proceedings;

hearings in the Workers Rehabilitation and Compensation Tribunal or Supreme Court;

claims involving factual disputes as to the cause of an injury;

claims involving disputes as to quantum;

claims involving disputes as to the status of the injured party - eg whether the injured party is an employee or a contractor;

claims involving possible fraud;

calculation of settlement figures;

preparing a Deed of Release;

requesting written reports from experts; and

interpreting and/or evaluating reports from experts.

In addition, claims involving major injuries (eg head and spinal injuries or multiple fractures) or latent injuries should be referred to the Office of the SG if it is likely that there will be a claim in a Court or Tribunal, or if it is anticipated that a settlement will be sought.

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