How a claim is assessed
When a claims manager receives your claim for workers' compensation, they must assess it to establish if it will be accepted under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act).
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 can be accepted.
For compensation to be payable under the 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 merit 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 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
- impairment.
Assessing the claim
The claims manager must also consider your claim against the following criteria:
Claim application complies with conditions
The 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).
Medical evidence
Your claims manager must consider the medical professional’s diagnosis of your injury or disease to decide if it is a compensable condition.
Diagnosis is based on:
- history
- examination
- testing.
A claims manager must establish whether the history on which the medical diagnosis is based is consistent with the information in your claim. If there is an inconsistency, your claims manager can:
- choose not to accept the medical diagnosis because it does not fully or accurately reflect the facts
- ask the medical 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 medical professional is more highly qualified.
It is important to note that medical professionals do not determine liability. It is your claims manager’s responsibility to determine liability in accordance with Comcare's function and powers under the SRC Act.
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 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).
For a full description of these requirements under the SRC Act, see sections 4, 5A, 5B, 6 and 7.
Exclusions from compensation
The 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.
Guiding principles
Under the SRC Act, a claims manager is guided by the following principles when assessing your claim:
No fault legislation
The 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.
Natural justice
To ensure that your claims manager meets their natural justice obligations, they may provide information to you, your employer, or a third party involved in the determination of your claim, such as a legal representative, in order for each party to supply evidence to support their claim/position. This information may include medical reports or other medical evidence in relation to your compensable injury.
Onus of proof
Under the 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.
The claims manager also has a legal right to obtain evidence to determine a claim. This power is provided under sections 57, 58 and 71 of the SRC Act.
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 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.
Case law
Many cases have gone before the courts about interpretation of phrases or words in the SRC Act.
The outcomes of these cases set legal precedent and your claims manager is required to consider these, if they are relevant to your claim.
