Eligibility for continuation of wages and medical benefits
Your employee's entitlement to weekly benefits is limited by the workers compensation legislation.
Unless their injury results in an impairment assessment in excess of 20 per cent (whole person impairment), their entitlement to weekly benefit will cease after five years.
Their ongoing entitlement to receive medical treatment is also limited and is linked to the date their weekly benefits cease. Medical treatment costs can be claimed for a limited period following the cessation of their weekly benefit.
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Eligibility for continuation of wages post 260 weeks
Eligibility for continuation of medical benefits
Eligibility for continuation of wages post 260 weeks
Within Section 39 of the Workers Compensation Act 1987, weekly benefits are available for a maximum period of 260 weeks (five years). Section 39 applies unless an injured worker has a permanent impairment (WPI) of more than 20 per cent.
Note: Section 39 does not apply to exempt categories of workers such as police officers, paramedics or firefighters, coal miners, volunteers prescribed by the Workers Compensation (Bush Fire, Emergency and Rescue Services) Act 1987, or other voluntary work or unpaid employment.
When does the week count towards your 260 weeks start?
- For claims made prior to 1 October 2012 ('existing claims'), the week count starts from 1 January 2013
- For claims made on or after 1 October 2012, the 260-week count starts on the worker's first day of incapacity which is paid on the claim.
Permanent impairment
For most workplace injury claims, a worker won't need a permanent impairment assessment. Although, if the claim is reaching 260 weeks, the Claims Service Provider (CSP) will need to find out their level of permanent impairment to review if they can receive weekly payment beyond 260 weeks.
If the worker is assessed as having a whole person impairment (WPI) of 20 per cent or less, they are not entitled to payments beyond 260 weeks (five years) and the CSP is required to notify them of the remaining number of weekly benefits on their claim.
Claims Service Provider contact
Your Claims Service Provider case manager will keep you informed of an injured worker who is approaching 260 weeks of weekly benefits.
If you have questions regarding a claim impacted by Section 39 you should contact your case manager to find out more information.
What happens to medical benefits?
If an injured worker has reached the maximum 260-week entitlements for weekly payments, they may be able to access reasonably necessary medical treatment dependent on their permanent impairment percentage.
My injured worker's weekly benefits are coming to an end, what now?
If an injured worker contacts you about their weekly benefits coming to an end, there may be other forms of support available. Please contact your case manager to discuss options which could be applicable to your worker's current circumstances.
Back to top ⇡Eligibility for continuation of medical benefits
Within Section 59A of the Workers Compensation Act 1987, after an injured worker's weekly benefits have ceased (aside from if a claim is disputed), an injured worker is still entitled to claim ongoing reasonably necessary medical benefits for a fixed period of time.
The specific time differs depending on the injured worker's assessed level of whole permanent impairment (WPI).
No assessment or WPI of 0-10%
For workers with no WPI assessment or permanent assessment as 0-10 per cent: Two years medical entitlement from when weekly payments stop, or from the date of claim if no weekly payments are made.
WPI of 11-20%
For workers with a WPI permanent assessment between 11-20 per cent: Five years medical entitlement from when weekly payments stop, or from the date of claim if no weekly payments are made.
High needs, WPI greater than 20%
For workers with high needs with a WPI assessment of greater than 20 per cent or if a medical assessor has declined to make an assessment as the worker has not reached maximum medical improvement (MMI).
In some circumstances, medical aids and applicable treatment can be considered a lifetime entitlement and are claimable for life. These benefits include home or vehicle modifications, crutches, eyes or teeth and other artificial aids such as hearing aids and hearing aid batteries.
What is the notice period?
An injured worker must be supplied with written notice 13 weeks before the end of medical entitlements. A nominated treating doctor and other treating parties must also be informed, to ensure they are aware that medical entitlements are coming to an end.
What support services are available to me?
An injured worker may still require medical treatment after medical entitlements cease.
An injured worker's medical and related treatment may be necessary to support wellbeing alongside rehabilitation and return to health.
Under these circumstances, your insurer should assist with providing the necessary support and ensuring an injured worker can access services through the public and private health system.
Resources: Where can you go for help?
Case manager
You can contact your case manager to discuss the worker's current situation. The case manager will be able to create a tailored plan of transition from the scheme in conjunction with their treatment providers.
Your Claims Service Provider also has access to some valuable initiatives such as Community Support Services.
Nominated Treating Doctor, specialist or allied health treating provider
The injured worker's treatment team may be able to assist with their transition off workers compensation. The doctor may be able to provide a mental health care plan, or access to other government-funded medical programs.
Financial support: Centrelink
If the injured worker is ineligible for weekly benefits due to Section 39, they should start their application for Centrelink 13 weeks prior to weekly benefits ceasing.
They should also source a letter from the insurer outlining how many weekly benefits have been paid, when weekly benefits are ceasing and the reason for cessation of weekly benefits.
They may also be required to supply Centrelink with up-to-date medical evidence and other supporting documents. They may also have to supply financial information such as any lump sums received, spouse earnings and so on.
Housing support
Housing pathways: if the injured worker requires assistance with housing they may find it beneficial to contact Housing support.
Mental health support
If the injured worker requires crisis or mental health support there are options available:
- Lifeline can assist with times in crisis and suicide prevention 24 hours a day.
- Beyondblue provides online support to assist with stressful circumstances.
- If they are suffering from a mental health condition and require support, they can contact Mental Health Line 24 hours a day on 1800 011 511.
- If you require support for an emergency, please contact 000.
