Information for General Practitioners Fact Sheet No 4

Accepting liability for a claim Executive summary For a claims manager to accept liability for a claim there must be

•  clear diagnosis
•  evidence that the injury or disease arose out of or in the course of the employee’s employment
•  in the case of a disease, a material contribution from the employee’s employment to the contraction of the disease Determining liability A claims manager needs to consider a number of issues when making a decision on liability for a claim. The first issue is to get a clear diagnosis of the condition. If the diagnosis is not clear, or the treatment provided appears to be inconsistent with the nature of the condition, the claims manager may need to seek further information from the treating doctor. In some cases, the claims manager may want to seek advice from a specialist not previously involved in the management of the claim. The claims manager will always be guided by the medical advice provided by doctors. Before liability can be accepted the claims manager must be satisfied that
•  the injury or aggravation arose out of or in the course of the employee’s employment
•  this occurred on the balance of probabilities not possibilities
•  if the diagnosed condition is a disease, there has been a material contribution from the employee’s employment to the contraction of the disease. The claims manager will have access to a range of information including the medical evidence, the employee’s claim, the employer’s statement and any witness or other evidence that may be of relevance in determining liability. Some claims will not be accepted even when there is a clear link to employment. The Safety, Rehabilitation and Compensation Act 1988 provides that diseases, injuries or aggravations are not covered for compensation purposes if these occurred as a result of reasonable disciplinary action taken against the employee or failure by the employee to gain a benefit such as a promotion. Contact with the treating doctor A claims manager may contact the treating doctor for additional information if this is needed to make a decision to either accept a claim or continue liability. Due to the nature of the decisions being made, this contact will probably be made in writing and a written response will be sought. In some cases however, a telephone call may be all that is needed to clarify an issue. If the treating doctor wants to discuss any matters related to an employee’s claim, then they are welcome to contact the claims manager to discuss the case. Other issues Claims managers will not accept backdated medical certificates and there are limits on the cost of therapeutic treatments available. Generally the AMA Schedule of Fees or WorkCover rates are used as the upper limit of what can be paid. Claims managers do not pay for treatments in advance of the treatment being provided. The claims manager will advise the employee if their claim has been accepted. The employee is then responsible for letting their doctor know if they are entitled to compensation benefits. If a claim is not accepted, then any unpaid accounts will be returned to the employee to arrange for their payment.