Invalid Claims

WorkSafe has been reviewing the way Agents and Employers deal with invalid claims and has identified some inconsistencies in the way invalid claims are managed.

If you are unsure how to determine whether a claim is valid you should contact your WorkSafe Agent directly and/ or forward the claim to the Agent for assessment. It is the Agent’s responsibility to assess the validity of claims and deal with them appropriately.

If you choose to return what you believe to be an invalid claim to a worker, you must provide written evidence as to why the claim was returned as invalid. If it is later determined that the claim was valid when it was first served by the worker, the 10 calendar day lodgement period will commence from when the valid claim was originally served.

The following section provides guidance on how invalid claims are to be dealt with and informs you of your obligations as an employer should they choose to return an invalid claim to a worker. 

• What constitutes a claim?
• What do I do when I receive a claim from a worker? 
• What do I do if the authority to release information in not signed?
• What do I do if I receive a claim for weekly payments and only receive a Claim Form with no medical certificates?
• What if I receive a claim form that does not have all the information filled in?

What constitutes a claim?

In simple terms a claim is made when the following documents are given or served on the employer and the employer forwards these documents to the Agent:

• A Medical & like expenses only claim (minor and standard): This is made when a Worker’s Injury Claim Form with the ‘Authority to Release Medical Information’ section signed is received.
• A weekly payments claim (minor and standard): This is made when a Worker’s Injury Claim Form with the ‘Authority to Release Medical Information’ section signed and medical certificates supporting the period for which weekly payments are claimed, are received.

This requirement is outlined in section 103(1) of the Accident Compensation Act 1985.

What do I do when I receive a claim from a worker? 

1. Complete Part 7 of the Worker’s Injury Claim Form (new claim form) titled ‘Employer Lodgement’ details or ‘Completion by Employer’ section of the old Worker’s Claim Form.(note: do not enter a date in the ‘when did you receive the worker’s medical certificate?’ unless you have received a medical certificate)
2. Provide written confirmation to the worker that you have received a claim from them. This can be done by giving or sending the worker a copy of the claim form when you have completed the appropriate section mention above. By way of best practice if you disagree with any of the following points it would be advisable to record this on a covering letter enclosing the copy of the claim form when providing the worker with written confirmation:
   • any of the lodgement dates specified on the claim form by the worker; and/or
   • the worker has not completed the ‘authority to release medical release information’ section of the claim form, and /or
   • the worker is making a claim for weekly payments and has not provided medical certificates in support.
3. Forward the claim documentation to the Agent. Any claim for weekly payments, or any claim for medical and like expenses above your excess must be forwarded to the Agent within 10 calendar days of being served on you by the worker. If the claim is for a medical and like expenses claim below your excess you have 3 months to forward to the Agent.

What do I do if the authority to release information in not signed?

If the worker provides you with a Worker’s Injury Claim Form (new claim form) or Worker’s Claim Form (old claim form) which does not have the authority to release information section signed you have two options:

• if the Claim Form is hand delivered to you, obtain the workers signature upon delivery.
• if the Claim Form is mailed to you, send the Claim Form back to the worker with a written request that:
  • the authority to release information be signed
  • new service dates be completed
  • the claim be returned to you.

In this instance we suggest that a copy of the Claim Form also be sent to the agent explaining that the original claim form has been returned to the worker and why.

OR

send the claim form to the agent who will then notify the worker that the authority to release information must be completed, new lodgement dates entered and the completed Claim Form be re-served on you.

Please note that the 10 day lodgement period commences when the completed Claim Form is served on you by the worker so it is important that the new service dates are recorded on the Claim Form when it is re-served on you by the worker.

What do I do if I receive a claim for weekly payments and only receive a Claim Form with no medical certificates?

If you receive a claim for weekly payments and only receive a Worker’s Injury Claim Form (new claim form) or Worker’s Claim Form (old claim form) without a medical certificate to support weekly payments then you must do the following:

• If the claim is also for medical and like expenses which is above the employers threshold then:
  • Forward the Claim Form to the Agent within 10 calendar days from service by the worker and advise the Agent in a covering letter that although the worker is also claiming weekly payments you are yet to be provided with a medical certificate in support.
  • Inform the worker that you require medical certificates to support their claim for weekly payments. The Agent will also notify the worker of the requirement to serve the medical certificates on you.
  • When the medical certificates are served on you, forward the medical certificates to the Agent within 10 calendar days from the date of service. 
• If the claim is also for medical and like expenses which is below the employers threshold then:
  • Inform the worker that you require medical certificates to support their claim for weekly payments.
  • When the medical certificates are served on you by the worker forward the Claim Form and the medical certificates to the Agent within 10 calendar days from the date of service of the medical certificates.

You should be mindful while waiting for the medical certificates to be served that if:

• you are provided with an invoice that tips the workers medical expenses above the employers threshold then the Claim Form will need to be lodged within 10 calendar days of the invoice being received.
• the under excess medical expenses claims is nearing the 3 month time period that the Claim Form will need to be forwarded to the Agent.

What if I receive a claim form that does not have all the information filled in?

If you receive a claim for weekly payments and only receive a Worker’s Injury Claim Form (new claim form) or Worker’s Claim Form (old claim form) which does not have all the information filled in by the worker then it should be forwarded to the Agent as soon as possible to enable the Agent to make a decision as to whether the claim form contains a material defect, omission or irregularity.

If the defect, omission or irregularity in the Claim Form is not relevant to the decision to accept or reject the claim for medical and like expenses (and weekly payments), the claim is treated as valid.

Given it is the Agent’s responsibility to assess whether the lack of information will effect a decision to accept or reject a claim it is advisable that you do not send a Claim Form back to a worker for this reason.

We reiterate that that if you choose to return a Claim Form to a worker with what you believe to contain a material defect, omission or irregularity, if it is later determined that the claim was valid (the lack of information did not effect the decision to accept or reject the claim) then the 10 calendar day lodgement period will commence from when the valid claim was served.