Claims management decision framework

The claims service model empowers the service provider teams to be responsible for claims decisions to improve efficiencies and ensure that icare has visibility of dispute resolution and cost management to result in fairer outcomes for injured workers and employers.

As part of the implementation of icare’s service model, icare has developed a claims management decision framework to reflect the Workers Compensation Act 1987 and Workplace Injury Management and Workers Compensation Act 1998.

This framework outlines decision responsibilities and accountabilities for appointed claims service providers and icare as the nominal insurer. Claims service providers are responsible and accountable for the majority of decisions such as initial liability decisions on claims, and where icare has final approval, the decision is made in a consultative way. icare is accountable for complex decisions, high cost services, issue resolution, complaints and disputes.

This framework does not change the accountability of the claims service providers for the day-to-day contact with the customer, or from providing a clear explanation of any decision that is made.

The table below sets out the accountability and responsibility for key claims management decisions as follows:

  • Accountable is the organisation ultimately answerable for the correct and thorough completion of the task or deliverable — the decision maker
  • Responsible is the organisation doing the work to achieve the task.

Claims decisions

The Claims Management Decision Framework applies to claims service providers appointed to manage claims on behalf of the Nominal Insurer only.
Responsible Accountable Additional information
Liability decisions including application of reasonable excuse and declining a claim. Claims service providers

The claims service provider is empowered to accept provisional liability or full liability, where appropriate. Where the liability decision is more complex, including situations where a reasonable excuse may be applied, or liability may need to be declined, a technical specialist at the claims service provider will assist in making the decision.

For more information please see SIRA’s Workers Compensation Guidelines and SIRA’s Claims Management Guide

Determining liability on fatality claims and significant claim events Claims service providers icare

A centralised team at icare is accountable for endorsing any liability decision associated with a fatality claim or high profile catastrophic incident, for example where there are multiple significant injuries or deaths.

Step 1:
The employer or worker lodges the claim(s) with their claims service provider.
Step 2:
The case manager gathers all information, liaises with all stakeholders and provides a recommendation to icare.
Step 3:
The icare fatality team endorses the recommendation.
Step 4:
The case manager is responsible for management of the claim and will keep all stakeholders informed within three working days or as required.
Approval of all estimates Claims service providers The claims service provider is responsible for conducting all claim estimates where these impact on the calculation of premium.
Treatment decisions Claims service providers The claims service provider is responsible for treatment decisions including whether a referral should be made to icare’s Medical Support Panel. See exception for new and experimental treatment procedures below.
New and experimental treatment procedures Claims service providers icare Any new and experimental treatment procedures must be approved by icare. Generally this includes treatment which does not have an Australian Medical Association (AMA) code.
Referral to Independent Medical Examiner (IME) Claims service providers Claims service providers / icare

If additional information is required to make a decision on treatment or medical causation (excluding psychological injuries), a referral must be made to the Medical Support Panel (MSP) for advice prior to referral to an IME.

In all other circumstances, the claims service provider makes the decision regarding whether to refer to an IME. This includes, medical causation for psychological injuries; work capacity and whole person impairment assessment.

Approval of surveillance Claims service providers icare

Surveillance can play an important role in the workers compensation scheme, but can significantly erode worker trust, so insurers are expected to use it judiciously. The use of discreet, covert surveillance of the worker’s level of injury and activities may be approved where there are grounds to suspect that the worker is misrepresenting their injury or recovery or may be involved in the commission of fraud. Referrals for investigations are to be made to icare’s panel.

For more information please see SIRA’s Standards of Practice and SIRA’s Claims Management Guide

Step 1: 
The case manager at the claims service provider will assess the reason for surveillance and the likelihood of success. At this stage they are also considering whether any less intrusive methods may be successful.
Step 2:
The case manager gathers all information, liaises with all stakeholders and sends a recommendation to icare.
Step 3:
icare’s litigation team review the recommendation within five working days of receipt.
Step 4:
The case manager is responsible for management of the claim and will keep all stakeholders informed.
Review privacy breaches and conflicts of interest icare icare will review all suspected or reported privacy breaches and all suspected or reported conflicts of interest.
Review of threats of self-harm or harm to others Claims service providers The claims service provider gathers all the information, liaises with all stakeholders and develops a recommendation for management of the threat. icare is notified of the threat within 24 hours and may facilitate access to specialist counselling, including 24/7 services, if this is needed for either the worker, employer or case manager.
Approval of high-value return to work (RTW) services, high-value items or other services Claims service providers icare Rehabilitation services are not intended to be a substitute for normal case management. The claims service provider approves costs, however icare monitors costs which are in excess of expectations for the specific service segment. An employer-preferred (or worker-preferred) provider is recognised. High-cost items such as home modifications; vehicle modifications; prosthetic requests and complex aids/equipment requests are to be approved by icare if the cost is over a specified amount.
Referral for rehabilitation and return to work (RTW) services Claims service providers

The claims service provider makes referrals for these services, including to employer/worker-preferred providers where appropriate.

Choice of service provider is respected where the employer or worker has a preference.

Approve Whole Person Impairment (WPI) determination less than 15 per cent Claims service providers The claims service provider approves the WPI determination where it is under 15 per cent.
Approve Whole Person Impairment (WPI) determination greater than or equal to 15 per cent icare In order to maintain threshold integrity and to ensure fairness across the scheme, icare will approve the WPI determination if equal or greater to 15 per cent. This includes any proactive offer made regarding WPI and the management of Workers Care claims.
Work capacity decisions (including adverse decisions) Claims service providers The claims service provider is responsible for making all work capacity decisions required on claims in accordance with legislation (Workers Compensation Act 1987 and Workplace Injury Management and Workers Compensation Act 1998).
Work capacity decision reviews and escalations icare icare retains responsibility for reviewing work capacity decisions where a customer has requested a review and also is responsible for any litigation relating to work capacity decisions (escalation of a decision to the Workers Compensation Commission).
Vocational programs and incentives Claims service providers Vocational programs and incentives are actioned and approved by the claims service provider.
Approval of legal referral for initial advice Claims service providers The claims service provider can directly refer for advice to a legal provider on a deed with icare for an initial advice on liability within the first 13 weeks of the claim.
Litigation and legal advice icare

With the exception of initial advice on liability in the first 13 weeks, icare is responsible for managing all other pre-litigation and litigation matters. This includes the engagement of legal providers for advice before and after litigation, engagement of legal providers to provide representation in litigation, instructing legal providers, receiving legal advice and determining litigation strategies. This applies to liability, compensation, Work Injury Damages, common law, dust disease and fatality claims, litigation in relation to third party recoveries and work capacity decisions and any other claim related litigation or legal advice.

Step 1:
The employer or worker lodges the claim with their claims service provider.
Step 2:
The technical specialist reviews the claim and determines if a legal referral is warranted or if there is a basis for a legal referral and then sends the claim to icare for approval.
Step 3:
The icare litigation team runs the litigation process and determines the strategy, in consultation with the claims service provider and the employer as appropriate.
Step 4:
The employer is regularly updated by the claims service provider and is advised of the outcome or settlement, if the employer is not present at the proceedings.
Independent Medical Exam for the purpose of establishing whether treatment is reasonably necessary or establishing medical causation for physical injuries Claims service providers

When is icare’s Medical Support Panel is consulted for Independent Medical Examinations?

  • If the nominated treating doctor or treating specialist has not responded to a request for specific information within 10 working days and further information is required to inform a decision on a request for treatment, surgery or other services
  • If further information is required to determine liability
  • When exploring suitable duties and employment options.
Suspension of benefits Claims service providers The claims service provider makes decisions regarding the suspension of benefits for non-compliance with return to work or work capacity assessment.
Escalated complaints icare

If a customer has a complaint, we first encourage them to discuss it with the claims service provider. If it cannot be resolved, icare reviews escalated complaints from employers, workers or other stakeholders that cannot be resolved by the claims service provider. If complaints cannot be resolved, a worker is entitled to lodge the complaint with WIRO and an employer with SIRA.

The icare complaints team can be contacted on 13 99 22.

Close or reopen a claim Claims service providers The claims service provider makes all decisions regarding the closure or reopening of a claim.