Injury Management Policy and Procedures

Claim management

Background

1.1 This integrated system of Injury Management has been designed to:

1.1.1 support Flinders University's mission, values and Rehabilitation Policy;

1.1.2 reflect the vision, mission, and outcome statements of the Claims Management Unit;

1.1.3 fulfil Legislative requirements

1.2 Flinders University aims to:

1.2.1 Provide teaching and research that ensures that the University is 'recognised widely as a community sensitive Australian university that is confident, supportive and outward looking…'1

1.2.2 Provide an in-house Rehabilitation service that is equitable, effective, supportive and ensures an early return to work.

1.2.3 Provide Workers Compensation claims management that is fair and equitable. To fulfil that aim, the Claims Management Unit administers claims management for University staff in accordance with the Claims Management Unit Vision Statement: "To provide comprehensive claims management which is recognised for fairness and quality of service to claimants and excellence in performance for the University" 2

1 Statement of Intent of the Flinders University Education and Research Policy, 2000
2 Vision Statement of Claims Management Unit

Purpose

2.1 The purpose of this document is to outline the requirements for the systematic management of Injury Management (Rehabilitation and Claims) at Flinders University.

Scope

3.1 This policy and procedures document applies to the systematic management of Injury Management at Flinders University.

Definitions

4.1 The definitions below are given in plain English.  For precise legal definitions please refer to Section 3 of the Workers Rehabilitation and Compensation Act, 1986.

4.1.1 Disability
The disability of a worker means any physical or mental injury, disease, disfigurement or death.

4.1.2 Income maintenance.
Income maintenance refers to normal wages.  It means maintaining income if an employee is off work due to a compensable disability.

4.1.3 Interim payment.
Continued payment of the worker’s normal salary in the period of time before the compensation claim has been determined if there is a delay in the determination process.  The staff member will be advised whether or not this payment will be made, and the reason for the delay in determination.  If the claim is rejected then any interim payment may be recovered from the worker.

4.1.4 Notional weekly earnings.
A staff member who is totally incapacitated for work will receive compensation based on their notional weekly earnings.  The ‘Notional Weekly Earnings’ amount is the amount the employee would expect to receive if they were at work.  However, some special allowances and overtime payments may not be included in this calculation.

Flinders University Injury Management Policy

5.1  Flinders University is committed to the provision of an Injury Management System that through the application of specific policies and procedures will:

5.1.1 achieve a reasonable balance between the interests of the University and the University staff;

5.1.2 promote the effective rehabilitation and early return to work of all staff members who have incurred work related injuries or illnesses; in accordance with the Flinders University Rehabilitation Policy;

5.1.3 have rehabilitation managed by the Flinders University's Rehabilitation Case Manager and compensation claims administered by the Claims Management Unit;

5.1.4 enable expeditious and fair claims management;

5.1.5 be structured in a manner that enables performance evaluation and the opportunity for continuous improvement.

5.2  The Procedures relating to this Policy are held in the Occupational Health and Safety Unit.

Claim Management

6.1 A claims administration manual will be maintained.

The Manager of the Claims Management Unit will monitor changes to legislation via information from:

• Self Insurers of South Australia;
• legislative update information from other newsletters and professional journals;
• all relevant information from WorkCover.

The Manager will update the manual in accordance with that information.

6.2 The Claims Management Unit is responsible for:

6.2.1 all aspects of claims management within the requirements of the Workers Rehabilitation and Compensation Act 1986 and the WorkCover Performance Standards including prompt determination of claims, reimbursement of medical expenses and determination of notional weekly earnings;

6.2.2 notifying injured employees when their Income Maintenance payment will be reduced to 80% of notional weekly earnings;

6.2.3 advising employees that their superannuation contribution rate may be affected when their income maintenance payments have been reduced to 80% and that they should contact the University Superannuation Officer;

6.2.4 notifying the OHS Unit where an injured employee’s Income Maintenance payment will be reduced to 80% notional weekly earnings;

6.2.5 advising the OHS Unit of section 42 lump sum redemptions.

6.3 Claim Process

6.3.1 Claims from staff members will be forwarded to the OHS Unit as soon as possible after injury.  The OHS Unit will date stamp claims received and forward them to the Claims Management Unit when received.

6.3.2 Upon receipt of an employee's claim, the Claims Management Unit 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.

6.4 Claim Determination

6.4.1 Consistent with the requirements of Section 53(4) of the Workers’ Rehabilitation and Compensation Act 1986, the Claims Management Unit will endeavour to provide the employee with a determination in relation to the claim within 10 business days of taking receipt of the employee’s claim.

6.4.2 Where a claim cannot be determined within 10 business days, the Claims Management Unit will communicate in writing to the employee, setting out the reasons why such determination has not been made.  The Claims Management Unit will also advise the employee of his/her rights to a course of action to expedite a decision.  In the claims decision process an offer of interim payments will be considered and case notes will be kept of the decision process.

6.4.3 An information kit of rights and responsibilities will be provided with the claims acknowledgement letter.

6.4.4 An employee may be placed on a rehabilitation plan or program before the claim has been determined.

6.4.5 The Rehabilitation Information Brochure that is provided to staff when they make a claim provides advice regarding rights and responsibilities.  This includes the right for staff members to choose their own treating medical expert.

6.4.6 In determining a claim the Claims Management Unit may do any of the following:

6.4.6.1 accept the claim for ongoing income maintenance and medical expenses reasonably incurred as a result of the disability;

6.4.6.2 accept the claim for a closed period of income maintenance and medical expenses reasonably incurred as a result of the disability;

6.4.6.3 accept the claim for medical expenses only, reasonably incurred as a result of the disability;

6.4.6.4 defer a decision to determine the employee’s claim pending further investigation;

6.4.6.5 reject the claim.

6.4.7 Where a determination is made in relation to an employee’s claim, the Claims Manager will also advise the claimant in writing of the Workers’ Compensation Dispute Resolution Process.

6.5 Income Maintenance

6.5.1 Income maintenance refers to normal wages.  It means maintaining income if an employee is off work due to a compensable disability.

6.5.2 A staff member who is totally incapacitated for work will receive compensation based on their notional weekly earnings.  ‘Notional Weekly Earnings’ is the amount the employee would expect to receive if they were at work.  However, some special allowances and overtime payments may not be included in this calculation.

6.5.3 If a staff member is partially incapacitated for work (i.e. on reduced hours of work) they will receive salary for the hours worked and Workers Compensation weekly payments for the remainder up to their normal hours of work.

6.5.4 After 12 months of incapacity for work, an employee’s Notional Weekly Earnings reduces to 80% of Notional Weekly Earnings.

6.6 Other Compensable Expenses

6.6.1 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 Workers’ Rehabilitation and Compensation Act, 1986.

6.6.2 Where an employee incurs a compensable expense, the employee shall provide evidence to the satisfaction of the Claims Management Unit demonstrating that such expense was reasonably incurred, together with expense receipts if required or an account from the provider of the medical service.

6.6.3 The employee must obtain prior approval from the OH&S Unit or the Claims Management Unit for certain expenses.  These include (but are not limited to):

• Surgery
• Dental/orthodontic
• Optical
• Podiatry
• Chiropractic
• Physiotherapy
• Massage
• Hydrotherapy
• Gym/swimming membership
• Acupuncture
• Speech Pathology
• Travel
• Home assistance
• Taxi

6.6.4 The Claims Management Unit will reimburse an employee who is entitled to be reimbursed for an expense by a cheque from the Claims Management Unit.

6.7 Responsibilities

6.7.1 Staff with particular responsibilities in relation to injury management are:

• all employees suffering an injury or illness;
• all Executive Deans of Faculties, Heads of Schools, Departments and Divisions, Directors, Managers, Supervisors;
• Executive Director of Administration;
• Manager Claims Management Unit;
• Rehabilitation Case Manager;
• Head of Occupational Health and Safety Unit;
• Payroll Officers;
• the Claims Reconsiderations Officer.

6.7.2 The Executive Director of Administration on behalf of the Vice Chancellor is accountable for ensuring that the Injury Management Policy and Procedures:

• comply with all relevant requirements of the WorkCover Performance Standards for Self Insurers; and
• meet the requirements of Flinders University; and
• are developed through consultation.

6.7.3 The Executive Director of Administration is also responsible for ensuring:

• that the monthly Injury Management meetings include review of objectives/targets/performance indicators, consideration of the need for rehabilitation assistance, discussion of requests for ergonomic assessment in relation to injury, and any grievances or complaints received in relation to injury management; and
• that the outcomes of the audits are documented and corrective actions taken where required, in priority order.

6.7.4 The Head of the Occupational Health and Safety Unit is accountable for ensuring that:

• the Injury Management Policy complies with all relevant requirements of the Performance Standards for Self Insurers and with the requirements of Flinders University;
• procedures supporting the Injury Management Policy and contingency arrangements are developed through consultation;
• an annual plan for injury management is developed through consultation;
• the Injury Management Policy identifies appropriate system objectives;
• the Injury Management Policy addresses legislative compliance as part of the system;
• the Injury Management Programs have key objectives, targets and performance indicators;
• action plans are in place to correct identified areas of non-conformance with documented procedures;
• the Rehabilitation Procedures Manual is updated annually;
• an injured worker satisfaction survey is conducted in accordance with the WorkCover Natural Consequences Measures;
• an annual program of internal auditing is undertaken.  This will require identifying:
  • when the audit will be carried out;
  • the range of files to be reviewed;
  • file review criteria required;
  • interview population to be established,

so that Heads, Managers, Supervisors, OHS Representatives and injured workers have confidence in the integrity of audit findings;

• outcomes of the audits are documented and corrective actions taken where required, in priority order;
• all injury management policies and procedures are reviewed for suitability and effectiveness annually through consultation;
• the level of achievement of objectives/targets/performance indicators are analysed and used to determine areas of success and corrective or preventative actions.  The Injury Management System is reviewed and revised in line with current legislation, the workplace and work practices and the measurement of outcomes from the system; and that
• in November each year an evaluation is carried out of rehabilitation processes against the Natural Consequences Model, with a view to obtaining 100% rating on each criteria.

6.7.5 The Manager of the Claims Management Unit is accountable for ensuring that the implementation of the Injury management System, through consultation, is effectively carried out, including;

• adequate human, physical and financial resources are being allocated to support the injury management program;
• specialist expertise is used as required;
• a relevant training program is being implemented;
• defined responsibilities are communicated to relevant employees;
• accountability mechanisms are being used when relevant;
• system elements are aligned with, or integrated into, other corporate/University business functions, when relevant;
• arrangements for employee consultation and involvement are known and integrated into the claims management process;
• communication arrangements for information dissemination and/or exchange are in place;
• contingency plans are periodically tested and/or evaluated to ensure an adequate response, if required;
• all other activities arising out of policies and/or procedures are being implemented;
• the relevant level of reporting, records and/or documentation is maintained to support the system programs and legislative compliance;
• program(s) of documentation control for identification and/or currency of essential documents is in place and being maintained;
• outcomes of the audits are documented and corrective action taken where required, in priority order.

6.7.6 The Rehabilitation Case Manager is accountable for:

• ensuring that, as soon as practicable after injury, workers' rehabilitation needs are identified and an assessment is made of the most appropriate rehabilitation facilities and services to ensure an early return to work; ensuring that workers are informed of the rehabilitation process and procedures, so that they are aware of their rights and responsibilities;
• assisting in identifying appropriate duties that satisfy the medical restrictions to ensure a safe return to meaningful work, and examining the need for modification of work sites, where necessary;
• working in consultation with the worker, the appropriate supervisor/manager, the treating medical experts, the external contracted rehabilitation provider, where involved, and the worker’s representative where requested, to structure a return to work plan;
• documenting the agreed plan where required, and ensuring a copy is provided to the worker and the appropriate supervisor/manager;
• ensuring the confidentiality of appropriate information amongst persons authorised for the purpose of rehabilitation;
• establishing and maintaining case files in a confidential manner;
• providing personal support to the worker and their family where appropriate during all stages of the rehabilitation process;
• convening case conferences, where required, to discuss progress with the relevant parties;
• monitoring and regularly reviewing all return to work plans to ensure:
  • The best practicable level of recovery
  • The health and safety of the worker undertaking to program
  • The on-going involvement of all relevant parties
  • The appropriateness of the tasks, in relation to the worker’s injury and recovery rate
  • The achievement of rehabilitation goals
• arranging for interpreters to assist in communicating rehabilitation objectives and programs to workers, where required;
• monitoring the need to modify rehabilitation policies and procedures, in consultation with relevant parties;
• providing accounts to appropriate people to ensure prompt reimbursement of workers expenses where equipment and/or facilities are required to assist the worker, and this forms part of the approved return to work plan.

This Policy will be reviewed every four years or more often should major organisational changes occur or should requests for revision be received by the University Occupational Health and Safety Committee.