How a claim is assessed
When a claims manager receives your claim they must assess it to establish if it will be accepted under the Safety, Rehabilitation and Compensation Act 1988.
When you submit a claim for a work-related injury or illness, your claims manager will review the information you have provided, along with evidence from your employer or medical practitioner. They will assess whether the application complies with conditions and other requirements and if liability is accepted.
For compensation to be payable under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act), your claims manager must find that liability for a claim relating to an injury or illness exists.
Finding liability is a confirmation of:
- what the claimed medical condition is
- whether the claimed injury or illness, or aggravation of either, is work-related.
If liability is accepted, each claim for income support, medical treatment or other entitlement must be assessed on its own before it can be accepted and paid.
Testing for liability
When determining liability, your claims manager applies three tests:
- a person must be an employee for the purpose of the Safety, Rehabilitation and Compensation Act 1988 (SRC Act) (section 5)
- there must be an injury or disease as defined by the SRC Act (sections 4, 5A, 5B, 6 and 7)
- an injury or disease must result in a loss, either:
- incapacity for work
- death, or
Assessing the claim
The claims manager must also consider your claim against the following criteria:
Claim application complies with conditions
The Safety, Rehabilitation and Compensation Act 1988 (SRC Act) requires that claims for compensation comply with certain conditions. These include that the claim must be:
- made by, or on behalf of, an employee, as defined in the SRC Act (section 5)
- lodged as soon as practicable (section 53)
- submitted on the approved form (section 54)
- accompanied by a medical certificate (where required) (section 54).
Your claims manager must consider the health professional’s diagnosis of your injury or disease to decide if it is a compensable condition.
Diagnosis is based on:
A claims manager must establish whether the history on which medical diagnosis is based is consistent with the information in your claim. If there is inconsistency, your claims manager can:
- choose not to accept the medical diagnosis because it does not fully or accurately reflect the facts
- ask the health professional, or an independent specialist, for clarification
- where there are conflicting medical diagnoses, make a decision based on the diagnosis with the most weight. For example, a diagnosis may have more weight because the health professional is more highly qualified.
It is important to note that health professionals do not determine liability. It is your claims manager’s responsibility to determine liability.
Relationship of injury or illness to work
Once your claims manager has determined whether your condition is defined as an injury or an ailment under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act), they must decide whether there is a relationship between your condition and your employment.
This involves establishing whether a condition:
- arose out of, or in the course of, your employment (for an injury)
- was contributed to, to a significant degree, by your employment (for a disease).
Exclusions from compensation
The Safety, Rehabilitation and Compensation Act 1988 (SRC Act), states that in some situations employees are excluded from receiving compensation. This includes:
- An injury, illness or aggravation sustained as a result of reasonable administrative action taken in a reasonable manner by an employer, in respect of an employee’s employment. Reasonable administrative action includes, but is not limited to:
- a reasonable appraisal of performance
- a reasonable counselling action (formal or informal)
- a reasonable suspension action
- a reasonable disciplinary action (formal or informal)
- failure to obtain a promotion, reclassification, transfer or benefit, or to retain a benefit in connection with work.
- An injury that is intentionally self-inflicted.
- An injury that is caused by serious and wilful misconduct (except where the injury results in death or serious and permanent impairment).
- Illness, where you have made a wilful and false representation that you did not, or had not, previously suffered from that illness, in connection with your employment.
Under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act), a claims manager is guided by the following principles when assessing your claim:
No fault legislation
The Safety, Rehabilitation and Compensation Act 1988 (SRC Act) provides a no-fault workers' compensation scheme. This means that you do not have to show that your employer has done anything wrong for an injury or illness to be eligible for compensation—the requirements for liability are set out by law.
Claims managers must observe the principle of natural justice. This means they must:
- provide opportunity for anyone who will be adversely affected by their decision to be heard
- be impartial or unbiased in any matter to be decided.
Onus of proof
Under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act), an employee has no legal onus of proof. This means you do not legally need to ‘prove’ a case.
However, you do need to satisfy the criteria of the SRC Act for your claim to be accepted.
Standard of proof
Standard of proof means the degree of certainty with which contested facts must be established in order to be accepted as proved.
Under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act), the basis for decisions is established on the 'balance of probabilities'. This means claims managers must decide that more likely than not, the fact or facts relied upon existed at the relevant time.
Many cases have gone before the courts about interpretation of phrases or words in the Safety, Rehabilitation and Compensation Act 1988 (SRC Act).
The outcomes of these cases set legal precedent and your claims manager considers these, if they are relevant to your claim.