FLINDERS UNIVERSITY
Claims Management at Flinders University
1.
Responsibilities
Claims Manager
Responsible for
 determining and administering claims in accordance with the
requirements of Workers Compensation legislation and WorkCover
SA Performance Standards for Self Insurers;
 providing information to injured staff members regarding their
entitlements under Workers Compensation legislation, performance
standards and procedures;
 advising the Rehabilitation and Return to Work Coordinator (R&RTW
Coordinator) of any reported injury or illness which may require
absence from work and/or workplace modifications;
 advising the Manager, OHS of any issues of concern.
Rehabilitation and
Return to Work
Coordinator
(R&RTW
Coordinator)
Responsible for
 notifying the Claims Manager as soon as the R&RTW Coordinator is
aware of any workplace injury or illness that may result in a claim for
compensation;
 providing relevant information to the Claims Manager; and
 liaising with the Manager, OHS, the Claims Manager and as
required, the Director, Human Resources regarding progress with
rehabilitation and/or return to work.
2.
Making a Claim
A staff member who sustains a work related injury or illness which results in medical
treatment and/or time lost from work can make a claim for compensation by completing, and
forwarding to the University R&RTW Coordinator, the following forms:
 Accident/Incident Report Form; and
 the relevant workers' compensation claim form for medical and associated costs.
All claims for compensation must be accompanied by a Workers Compensation Medical
Certificate.
The R&RTW Coordinator will forward completed Claims Forms to the Claims Manager within
two business days of receipt and all other relevant documentation as soon as practicable.
The claimant will utilise sick leave or other accrued leave entitlements until the claim is
determined.
3.
Investigating a Claim
The Claims Manager will investigate and make enquiries as required to assist in the
determination of the claim. These may include taking a statement from the injured staff
member and/or witnesses and any other relevant parties and/or obtaining medical reports or
other investigations as deemed necessary by the Claims Manager. Any medical reports
obtained by the Claims Manager must be forwarded to the injured staff member within seven
business days. Copies of medical reports obtained are also forwarded to the R&RTW
Coordinator.
4.
Independent Medical Examinations
The University may require the injured staff member to attend an independent examination
by a medical practitioner to assess the nature and extent of the injury. A copy of the medical
report must be sent to the staff member within seven business days and copies forwarded to
the R&RTW Coordinator, and treating medical practitioner(s).
Failure to attend a medical examination may cause a delay in the determination of a claim,
and may provide a basis for claim rejection.
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5.
Claim Determination
The Claims Manager is responsible for accepting or rejecting a claim or deciding to seek
further information. All determinations will be made within ten business days of receipt of the
claim, except where the Claims Manager notifies the injured staff member that further
medical evidence and/or enquiries are required.
6.
Accepted Claim
Where the claim is accepted, the Claims Manager will advise the injured staff member in
writing within two business days of the determination and of their rights and responsibilities.
7.
Rejected Claim
Where the Claims Manager proposes to reject a claim for compensation, the Claims
Manager will advise the injured staff member and/or their representative of the decision and
the reasons for the rejection in writing within two business days of the determination.
8.
Deferred Claim
Where a determination on a claim for compensation cannot be made within ten business
days, the Claims Manager will contact the staff member and/or their representative and
explain the reasons for the delay, and those actions that are required in order to make a
determination. The Claims Manager will also provide this advice in writing to the staff
member, including information on how to request an expedited decision.
The staff member will be advised that medical and related costs will be held in abeyance until
a determination is made.
9.
Claims Disputes
A staff member who is not satisfied with a decision in relation to a claim for compensation
may apply to the Workers Compensation Tribunal (SA), the Accident Compensation
Conciliation Service (ACCS) (Vic), or the Work Health Court (NT) for a review of the decision.
The staff member is required to complete a Notice of Dispute and lodge this with the Workers
Compensation Tribunal or relevant interstate authority within one month after receipt of the
written determination.
If the Claims Manager is aware that a staff member is dissatisfied with a decision on a
determination, the Claims Manager will contact the staff member in an attempt to resolve the
issue before commencement of formal proceedings.
Once a Notice of Dispute is received by the Claims Manager, the Claims Manager must
notify the University’s Reconsideration Officer. The Reconsideration Officer will review the
claim and the basis of the disputed decision and determine to confirm or vary the decision.
The Claims Manager will forward the re-determination to the Workers Compensation Tribunal
or relevant interstate authority and the staff member and/or their representative within the
required time frame as stipulated by the Workers Compensation Tribunal or relevant
interstate authority.
If the injured employee disputes the varied or confirmed decision, the dispute will then be
heard at the Workers Compensation Tribunal or relevant interstate authority.
The Claims Manager will participate in all conferences at the Workers Compensation
Tribunal or relevant interstate authority and liaise with all parties to facilitate a resolution of
the disputed decision.
10.
Interim Payments
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Where there is a delay in the determination of a claim, the injured staff member may apply to
the Claims Manager for interim payments, which will be approved unless there are specific
circumstances that indicate the claim may be rejected.
Before seeking interim payments, the injured staff member should use any entitlements to
sick leave or annual leave, pending determination of the claim.
If the claim is ultimately accepted, such leave will be reinstated. If interim payments are
sought, the staff member is required to sign an Application for Interim Payment(s) Form.
The Claims Manager exercises the discretion whether to make Interim Payments. The
Claims Manager must explain to the staff member that if the claim is rejected, the University
is entitled to recover the amount of interim payments as a debt from the staff member
11. Payment of Medical and Other Expenses
Where a claim for compensation is accepted, all reasonable and relevant medical expenses
and all approved rehabilitation costs will be met by the University subject to limits imposed by
regulation.
Where an injured staff member incurs a compensable expense, the staff member will provide
evidence to the satisfaction of the Claims Manager showing that such expense was
reasonably incurred, and will provide expenses receipts or an account from the provider of
the medical service.
Injured staff members wishing to obtain treatment from people other than medical
practitioners or other registered medical experts, must seek approval before starting the
treatment. The University is not required to pay for such services, but may do so if approved
by the Claims Manager.
When surgery is proposed the injured staff member must seek approval from the Claims
Manager prior to undertaking the treatment. Prior to agreeing to meet the cost, the Claims
Manager may need to obtain a medical report from the treating specialist and/or independent
specialist. A copy of the resulting report will be provided to the staff member within seven
days of receipt.
12. Rejected Costs
Where the Claims Manager decides not to meet an expense incurred, the Claims Manager
will advise the staff member in writing including the details of the decision and the staff
member’s right to dispute the decision and lodge a Notice of Dispute with the Workers
Compensation Tribunal.
13. Confidentiality
All information regarding injured staff members will be kept confidential and made available
only as required to enable proper claims management
14. Contingency Arrangements
In the event of key staff being unavailable, the Manager, OHS or Director Human Resources
will make appropriate arrangements to ensure that continued effective claims management is
practiced in accordance with these procedures.
15. Audits
An audit of claim files will be conducted regularly to measure the performance of claims
management in accordance with legislation and WorkCover Performance Standards for Self
Insurers, these procedures and the Injury Management Action Plan.
The outcomes of this audit will be reported to the Manager, OHS.
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The Claims Manager will develop a Corrective Action Plan addressing any issues and/or
non-compliance arising out of the Audit report. The Claims Manager will address and
implement actions documented in the Corrective Action Plan and report on progress by the
nominated dates.
16. Staff located in States other than South Australia
Where University staff are based in University premises in other States, the following
legislation applies:
Victoria
Accident Compensation Act 1985
Accident Compensation (WorkCover Insurance) Act 1993.
Northern Territory
Workers Rehabilitation and Compensation Act 2008
Workers Rehabilitation and Compensation Regulations 2008
Flinders University policies and procedures (which apply at all University premises
regardless of location):
Occupational Health, Safety and Welfare Policy
Rehabilitation Procedures
17. Review
This Manual will be reviewed regularly in the light of legislative and organisational changes,
and in any case, every four years.
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