Guidelines for work capacity decision Internal Reviews by insurers and Merit Reviews by the Authority - original

Workers Compensation Act 1987

Workplace Injury Management and Workers Compensation Act 1998

I, Julie Newman, Chief Executive Officer of the WorkCover Authority of New South Wales, under section 376(1)(c) of theWorkplaceInjury Management and Workers Compensation Act 1998(NSW) and section 44(1) of theWorkers Compensation Act 1987 (NSW), issue the following guidelines.

Dated this day of October 2013.

Julie Newman PSM
Chief Executive Officer
WorkCover Authority of NSW

Guidelines for work capacity decision
Internal Reviews by insurers and
Merit Reviews by the Authority

These Guidelines are issued pursuant to section 376(1)(c) of theWorkplaceInjury Management and Workers Compensation Act 1998(NSW) and section 44(1) of theWorkers Compensation Act 1987 (NSW). The Guidelines set out the procedures to be followed by insurers, workers and the WorkCover Authority when carrying out a review of work capacity decisions.

These Guidelines come into effect on 11 October 2013.

Explanatory note

These Review Guidelines;

  • are made with respect to the procedures to be followed by insurers and workers in undertaking an internal review of a work capacity decision under section 44 of theWorkers Compensation Act 1987(NSW) (‘the 1987 Act’) of.
  • are made under section 376(1)(c) of theWorkplace Injury Management and Workers Compensation Act 1998(NSW) (‘the 1998 Act’) and section 44(1) of the 1987 Act internal review by insurers and operate by force of law as if they were delegated legislation.
  • are to assist implement and give effect to the operation of those sections of the 1987 Act relating to the Review by insurers of work capacity decisions made by insurers, and to instruct insurers and workers, and legal and other representatives of those parties how to make and deal with such applications for Review to be determined under the provisions of the 1987 Act.
  • are to assist implementation and give effect to the operation of those section of the 1987 Act relating to the review by the Authority of work capacity decisions.
  • are made to communicate to workers and employers to processes and procedures that will be used by the Authority relating to the review of a work capacity decision.

This new version of the Review Guidelines replaces the previous Review Guidelines gazetted 28 September 2012 and 7 December 2012. It applies to all new applications for review received by insurers and the Authority on or after 11 October 2013 and to all reviews lodged with insurers and the Authority at that date, that have not been determined.

Questions about these Guidelines should be directed to the Director, Assessment Services.

Julie Newman PSM
Chief Executive OfficerSafety Return to Work and Support Division

Geniere Aplin
General Manager, Workers Compensation Insurance
WorkCover Authority of NSW
Safety Return to Work and Support Division

Cameron Player
Director, Assessment Services
Motor Accidents Authority of NSW and WorkCover Authority of NSW
Safety Return to Work and Support Division

Division 1. Introduction

1. Commencement, Definitions

1.1 These guidelines may be referred to as the‘Review Guidelines’ and are made pursuant to section 44(1) of the 1987 Act and section 376(1)(c) of the 1998 Act. They apply in respect of all claims made by a worker, before or after 1 October 2012. Division 2 of these Guidelines, Internal Review by Insurers is delegated legislation.

1.2 These Review Guidelines replace the Review Guidelines that came into effect on 1 January 2013. They apply to all new applications for review received by insurers and the Authority on or after the date of their gazettal.

1.3 To the extent that they are not defined in clause 1.4, the words and expressions as defined in sections 3, 4 and 32A of the 1987 Act, and sections 4, 42 and 70 of the 1998 Act, apply to these Review Guidelines.

1.4 The terms used in these Review Guidelines have the following meanings:

1.4.1 1987 Act Workers Compensation Act 1987

1.4.2 1998 Act Workplace Injury Management and Workers Compensation Act 1998

1.4.3 Application The means by which a worker requests the referral of a work capacity decision by an insurer for a Review

1.4.4 Authority WorkCover Authority of NSW, an agency in the Safety, Return to Work and Support Division

1.4.5 Days A reference in these Guidelines to a number of days is a reference to a number of calendar days, unless otherwise stated

1.4.6 DX box Exchange box in the Australian Document Exchange Pty Ltd

1.4.7 ECM system An electronic case management system established by the Authority

1.4.8 Electronic Transactions Act Electronic Transactions Act 2000

1.4.9 Form A form approved by the Authority that may be an a pplication and/or a reply to an application

1.4.10 WIRO The WorkCover Independent Review Officer

1.4.11 WorkCover Independent Review Officer The person holding office under Chapter 2, Part 3 of the 1987 Act who may conduct a final work capacity review after an internal review by the insurer and a review by the Authority.

1.4.12 Insurer Any party against whom a claim is made under the Workers Compensation Acts

1.4.13 Internal Reviewer The person conducting an internal review by the insurer of a work capacity decision made by the insurer

1.4.14 Matter The application, reply and all supporting documents and correspondence held by the Authority in relation to one discrete application for review by the Authority. Each matter lodged with the Authority is given a discrete matter number.

1.4.15 Merit Reviewer The person conducting a review by the Authority of a work capacity decision made by an insurer

1.4.16 Officer An officer of the Authority undertaking work in relation to Reviews of work capacity decisions as directed by, or as delegated by the Director, Assessment Services

1.4.17 Regulation Workers Compensation Regulation 2010

1.4.18 Reply The means by which an insurer answers an application lodged by a worker seeking a Review by the Authority

1.4.19 Workers Compensation Acts TheWorkers Compensation Act 1987and theWorkplace Injury Management and Workers Compensation Act 1998

2. Time, Delivery of documents, ECM system

Reckoning of time

2.1 Any period of time fixed by these Guidelines for doing something is to be considered in accordance with clauses 2.2 and 2.3.

2.2 Where a time of 1 day or longer is to be calculated by reference to a given day or event, the given day or the day of the given event is not counted.

2.3 Where, apart from this sub-clause, the period in question, being a period of 5-days or less, would include a weekend or public holiday, those days are to be excluded.

Delivery of documents

2.4 Unless documents are lodged via an ECM system, delivery to an address for service is taken to have been effected at the following times:

2.4.1 in the case of a physical address, on the day the document is left at that address;

2.4.2 in the case of a postal address, on a day 4 days after the document is posted;

2.4.3 in the case of an email address, on the day the email or email attachment is sent if sent before 5:00pm, or on the day after the email or email attachment is sent if sent at or after 5:00pm; or

2.4.4 in the case of a facsimile number, on the day the facsimile is sent if sent before 5:00pm, or on the day after the facsimile is sent if sent at or after 5:00pm.

2.5 Formatterslodged via the ECM system, for the purpose of these Guidelines the provisions of section 13 of theElectronic Transactions Actapply.

Electronic case management system

2.6 The Authority may establish an ECM system to do one or more of the following:

2.6.1 enable documents with respect to applications for review to be created, exchanged, filed, issued and used in electronic form;

2.6.2 enable parties to applications for review to communicate in electronic form with the Authority and with other parties to those disputes;

2.6.3 enable information concerning the progress of applications to the Authority for review to be provided in electronic form to parties to those disputes; and/or

2.6.4 enable the Authority to communicate in electronic form with parties to applications for review.

2.7 The Authority may establish a protocol for the use of the ECM system, and for persons to become registered users of the ECM system.

2.8 The protocol established under clause 2.7 may provide, amongst other things, for the specification of the level of access to the system to which persons or specified classes of persons are entitled, the conditions of use of the system applicable to persons generally or persons of any such class, the security methods by which persons using the system are identified and verified, and how users gain access to the system.

2.9 Subject to any protocol established under clause 2.7, a person may not use the ECM system for particular applications unless the person is a registered user of the ECM system and is:

2.9.1 a party to the application for review; or

2.9.2 a person representing a party to the application for review.

2.10 In relation to any application for review, the level of access to the ECM system to which a user is entitled, and the conditions of use applicable to a user, are subject to any decision of the Authority.

2.11 Documents and information lodged via the ECM system may be dealt with in accordance with the provisions of theElectronic Transactions Act.

2.12 When the Authority sends documents, or forwards correspondence to a party who is a registered user of the ECM system, the Authority will generally only do so via electronic communication to that party.

3. Workers Compensation System Objectives

3.1 The 1998 Act sets out its purpose in section 3 as follows:

3 System objectives

The purpose of this Act is to establish a workplace injury management and workers compensation system with the following objectives:

  1. to assist in securing the health, safety and welfare of workers and in particular preventing work-related injury,
  2. to provide:
    1. prompt treatment of injuries, and
    2. effective and proactive management of injuries, and
    3. necessary medical and vocational rehabilitation following injuries,
    4. in order to assist injured workers and to promote their return to work as soon as possible,

  3. to provide injured workers and their dependants with income support during incapacity, payment for permanent impairment or death, and payment for reasonable treatment and other related expenses,
  4. to be fair, affordable, and financially viable,
  5. to ensure contributions by employers are commensurate with the risks faced, taking into account strategies and performance in injury prevention, injury management, and return to work,
  6. to deliver the above objectives efficiently and effectively.

3.2 In exercising their functions and interpreting the provisions of these Guidelines insurers, the Authority and its officers should have regard to these system objectives.

4. Work capacity decisions and Reviews

4.1 An application may be made by a worker for a review of a work capacity decision by an insurer in accordance with section 44 of the 1987 Act:

4.1.1 to an insurer for an internal review, and then;

4.1.2 to the Authority for a merit review, and then;

4.1.3 to the WIRO for a procedural review.

4.2 Work capacity decisions by insurers are defined in section 43 of the 1987 Act, which states:

43 Work capacity decisions by insurers

  1. The following decisions of an insurer (referred to in this Division as work capacity decisions) are final and binding on the parties and not subject to appeal or review except review under section 44 or judicial review by the Supreme Court:
    1. a decision about a worker’s current work capacity,
    2. a decision about what constitutes suitable employment for a worker,
    3. a decision about the amount an injured worker is able to earn in suitable employment,
    4. a decision about the amount of an injured worker’s pre-injury average weekly earnings or current weekly earnings,
    5. a decision about whether a worker is, as a result of injury, unable without substantial risk of further injury to engage in employment of a certain kind because of the nature of that employment,
    6. any other decision of an insurer that affects a worker’s entitlement to weekly payments of compensation, including a decision to suspend, discontinue or reduce the amount of the weekly payments of compensation payable to a worker on the basis of any decision referred to in paragraphs (a)–(e).
  2. The following decisions are not work capacity decisions:
    1. a decision to dispute liability for weekly payments of compensation,
    2. a decision that can be the subject of a medical dispute under Part 7 of Chapter 7 of the 1998 Act.
  3. The Commission does not have jurisdiction to determine any dispute about a work capacity decision of an insurer and is not to make a decision in respect of a dispute before the Commission that is inconsistent with a work capacity decision of an insurer.

4.3 Jurisdiction for internal review by insurers, and merit review by the Authority, is established in section 44 of the 1987 Act. Those provisions as relevant are extracted in later sections of this Guideline relating to each specific review.

Legal practitioners may not recover costs from a worker or insurer

4.4 Workers’ legal costs in relation to the review of work capacity decisions are referred to specifically in section 44(6) of the 1987 Act, which states:

A legal practitioner acting for a worker is not entitled to be paid or recover any amount for costs incurred in connection with a review under this section of a work capacity decision of an insurer.”

4.5 Insurers’ legal costs in relation to the review of work capacity decisions are referred to specifically in Schedule 8, clause 9 of the Regulation, which states:

A legal practitioner is not entitled to be paid or recover any amount for a legal service provided to an insurer in connection with an internal or other review under section 44 of the 1987 Act in relation to a work capacity decision of the insurer.”

Review of work capacity decisions—legal costs of insurers

A legal practitioner is not entitled to be paid or recover any
amount for a legal service provided to an insurer in connection
with an internal or other review under section 44 of the 1987 Act
in relation to a work capacity decision of the insurer.

Information for workers

4.6 Workers may obtain information about work capacity decision and review processes from the WorkCover Customer Service Centre on 13 10 50.

Division 2. Internal Review by insurers

5. Internal Review by insurers

5.1 A worker who has received a work capacity decision from an insurer may make an application to the insurer for an internal review of the work capacity decision, in accordance with the relevant provisions of the 1987 Act.

5.2 The jurisdiction for internal review by insurers is established in section 44 of the 1987 Act, and the relevant parts of that section are emphasised in bold below:

44 Review of work capacity decisions

  1. An injured worker may refer a work capacity decision of an insurer for review:
    1. by the insurer (an internal review) in accordance with the WorkCover Guidelines within 30-days after an application for Internal Review is made by the worker, or
    2. by the Authority (as a merit review of the decision), but not until the dispute has been the subject of internal review by the insurer, or
    3. to the Independent Review Officer (as a review only of the insurer’s procedures in making the work capacity decision and not of any judgment or discretion exercised by the insurer in making the decision), but not until the dispute has been the subject of internal review by the insurer and merit review by the Authority.
  2. An application for review of a work capacity decision must be made in the form approved by the Authority and specify the grounds on which the review is sought. The worker must notify the insurer in a form approved by the Authority of an application made by the worker for review by the Authority or the Independent Review Officer.
  3. The following provisions apply to the review of a work capacity decision when the reviewer is the Authority or the Independent Review Officer:
    1. an application for review must be made within 30 days after the worker receives notice in the form approved by the Authority of the insurers decision on Internal Review of the decision (when the application is for review by the Authority) or the Authority’s decision on a review (when the application is for review by the Independent Review Officer),
    2. an application for review by the Authority may be made without an Internal Review by the insurer if the insurer has failed to conduct an Internal Review and notify the worker of the decision on the Internal Review within 30-days after the application for Internal Review is made,
    3. the reviewer may decline to review a decision because the application for review is frivolous or vexatious or because the worker has failed to provide information requested by the reviewer,
    4. the worker and the insurer must provide such information as the reviewer may reasonably require and request for the purposes of the review,
    5. the reviewer is to notify the insurer and the worker of the findings of the review and may make recommendations to the insurer based on those findings (giving reasons for any such recommendation),
    6. the Independent Review Officer must also notify the Authority of the findings of a review and the Authority may make recommendations (giving reasons for any such recommendations) to the insurer based on those findings,
    7. recommendations made by the Authority are binding on the insurer and must be given effect to by the insurer,
    8. recommendations made by the Independent Review Officer are binding on the insurer and the Authority.
  4. A review of a work capacity decision does not operate to stay the decision or otherwise prevent the taking of action based on the decision.
  5. The Commission is not to make a decision in proceedings concerning a dispute about weekly payments of compensation payable to a worker while a work capacity decision by an insurer about those weekly payments is the subject of a review under this section.
  6. A legal practitioner acting for a worker is not entitled to be paid or recover any amount for costs incurred in connection with a review under this section of a work capacity decision of an insurer.”

6. Applications to insurers for Internal Review

Form of application – Section 44(2) 1987 Act

6.1 Anapplication for internal review must be made to the insurer by the worker in the form approved by the Authority, available on the Authority’s website at http://www.workcover.nsw.gov.au. The form approved by the Authority for that purpose is the‘Work capacity – application for internal review by insurer’ form.

6.2 The application form must set out the grounds on which the review is being sought and may attach any new or additionalinformation relevant to the work capacity decision.

6.3 An insurer may decline to review a decision if an application for review is not lodged in the form approved by the Authority.

6.4 A worker may be assisted in completing the application form by another person such as the insurer, a support person, agent, union representative, employer, legal representative, orinterpreter.

(Note: Legal practitioners may not recover costs from a worker or insurer, see Clause 4.4 and 4.5.)

Timely lodgement – Section 44(4) 1987 Act

6.5 An application for internal review should be lodged by the worker with the insurer as soon as practicable after receiving the work capacity decision from the insurer, noting that a work capacity decision is not stayed by any review process relating to that decision.

6.6 Section 44(4) of the 1987 Act states:

(4) A review of a work capacity decision does not operate to stay the decision or otherwise prevent the taking of action based on the decision.”

Non-Review of an application – Section 44(3)(b) 1987 Act

6.7 If an insurer declines to conduct an internal review for any reason or fails to conduct the review within 30 days as required by Section 44(1)(a) of the 1987 Act , the decision by the insurer, or its failure to conduct the review, exhausts the internal review process by the insurer. The worker may then apply for a Merit Review by the Authority.

6.8 An insurer must give notice in writing to the worker of the reasons for declining to conduct an internal review for any reason, including information satisfying the requirements of guideline 7.7 which is made under section 44(3)(a) of the 1987 Act.

6.9 Any application by a worker for review of an insurer’s decision to decline (or the insurer’s failure to conduct) an internal review application must be made within 30 days of the date of the notice given by the insurer to the worker, or where no notice has been given, within 30 days of the date that the insurer’s internal review decision was due.

Multiple work capacity decisions or claims

6.10 An application may refer for internal review more than one work capacity decision, about one or more of the worker’s related claims that are managed by the same insurer, however the time limit requirements must be met for each work capacity decision.

6.11 The insurer may determine whether or not such internal reviews of multiple work capacity decisions are most appropriately conducted together or separately as is appropriate in the circumstances of each particular case.

7. Internal Review process and decisions

Acknowledgement of application

7.1 The insurer shall write to the worker as soon as practicable and preferably within 7-days of receiving the application for review to acknowledge receipt of the application and to:

7.1.1 explain the review process that will be undertaken;

7.1.2 confirm that a review of a work capacity decision does not operate to stay the decision or otherwise prevent the taking of action based on the decision;

7.1.3 confirm that the worker may provide any new or additional information relevant to the work capacity decision and advising when that information is due to be received; and

7.1.4 indicate when and how the decision will be conveyed to the worker.

Internal Reviewer and decision

7.2 The internal review is to be undertaken by a person who was not involved in the making of the original work capacity decision.

7.3 The internal review is to be conducted by a person with the appropriate level of knowledge, expertise and skill relevant to the particular work capacity decision referred.

7.4 The Internal Reviewer may request additional information from the worker, and if doing so should allow the worker no less than 7-days to supply any such information.

7.5 The Internal Reviewer is to consider all of the material substantively and on its merits as if the original work capacity decision had not been made, and is obliged to make the decision that they think is more likely than not to be correct.

Notice of the Internal Review decision within 30 days – section 44(1)(a) 1987 Act

7.6 The insurer must write to the worker within 30-days of receiving the application advising of the outcome of the internal review and if the insurer fails to do so the worker may then make an application for merit review by the Authority.

Notice in the form approved by the Authority – section 44(3)(a) 1987 Act

7.7 The notice of the decision must be in the form approved by the Authority, must be in writing and must include:

7.7.1 details of the decision and its impacts:

7.7.2 a statement of reasons which includes the following:

7.7.2.1 findings on material questions of fact, referring to the documents or other material on which those findings were based;

7.7.2.2 the Internal Reviewer's understanding of the applicable law and rules, including the legislation, regulations or guidelines;

7.7.2.3 the reasoning process that led the Internal Reviewer to the decision.

7.7.3 advice to the worker about the availability of further review options including:

7.7.3.1 that the worker may make an application to the Authority for a merit review within 30-days after receipt of the internal review decision;

7.7.3.2 a copy of, or a website link to, the application form approved by the Authority; and

7.7.3.3 advice on where and how such an application is to be made.

7.8 The internal review decision does not replace the original work capacity decision by the insurer, which is not stayed by any review process under section44(4) of the 1987 Act. Theinternal review decision is a new decision by the insurer, which must take effect independently of the original decision.

Legislative Notice requirements apply to new work capacity decisions

7.9 If as a result of the internal review the Insurer makes a new work capacity decision, any relevant legislative notice requirements applicable to that new work capacity decision must be complied with by the insurer before they have effect, including the requirements of;

7.9.1 Section 54 of the 1987 Act regarding‘Notice required before termination or reduction of payment of weekly compensation’. As section 54(4) of the 1987 Act requires the insurer to give notice personally or by post, the postal service rule is automatically invoked. The postal service rule (section 76(1)(b) of theInterpretation Act 1987) requires an additional 4 working days notice to be provided after the notice was posted; and

7.9.2 Clause 21, Schedule 8 of the Regulation regarding‘Notice of increase in weekly payments of compensation’for‘existing recipients of weekly payments’, that is an injured worker in receipt of weekly payments immediately prior to 1 October 2012.

Division 3. Merit Review by the Authority

8. Merit Review by the Authority

8.1 The material provided under this Division is guidance material that demonstrates how the Authority will put into effect the provisions of the 1987 Act with respect to review of work capacity decisions by the Authority and communicate to workers and employers the processes and procedures used by the Authority.

8.2 A worker may refer a work capacity decision to the Authority for merit review, but only after the dispute has been the subject of an internal review by the insurer, in accordance with the relevant provisions of the 1987 Act.

8.3 The jurisdiction for merit review by the Authority is established in section 44 of the 1987 Act, and the relevant parts of that section are emphasised in bold below:

44 Review of work capacity decisions

  1. An injured worker may refer a work capacity decision of an insurer for review:
    1. by the insurer (an internal review) in accordance with the WorkCover Guidelines within 30-days after an application for Internal Review is made by the worker, or
    2. by the Authority (as a Merit Review of the decision), but not until the dispute has been the subject of Internal Review by the insurer, or
    3. to the Independent Review Officer (as a review only of the insurer’s procedures in making the work capacity decision and not of any judgment or discretion exercised by the insurer in making the decision), but not until the dispute has been the subject of internal review by the insurer and merit review by the Authority.
  2. An application for review of a work capacity decision must be made in the form approved by the Authority and specify the grounds on which the review is sought. The worker must notify the insurer in a form approved by the Authority of an application made by the worker for review by the Authority or the Independent Review Officer.
  3. The following provisions apply to the review of a work capacity decision when the reviewer is the Authority or the Independent Review Officer:
    1. an application for review must be made within 30 days after the worker receives notice in the form approved by the Authority of the insurers decision on Internal Review of the decision (when the application is for review by the Authority) or the Authority’s decision on a review (when the application is for review by the Independent Review Officer),
    2. an application for review by the Authority may be made without an Internal Review by the insurer if the insurer has failed to conduct an Internal Review and notify the worker of the decision on the Internal Review within 30-days after the application for Internal Review is made,
    3. the reviewer may decline to review a decision because the application for review is frivolous or vexatious or because the worker has failed to provide information requested by the reviewer,
    4. the worker and the insurer must provide such information as the reviewer may reasonably require and request for the purposes of the review,
    5. the reviewer is to notify the insurer and the worker of the findings of the review and may make recommendations to the insurer based on those findings (giving reasons for any such recommendation),
    6. the Independent Review Officer must also notify the Authority of the findings of a review and the Authority may make recommendations (giving reasons for any such recommendations) to the insurer based on those findings,
    7. recommendations made by the Authority are binding on the insurer and must be given effect to by the insurer,
    8. recommendations made by the Independent Review Officer are binding on the insurer and the Authority.
  4. A review of a work capacity decision does not operate to stay the decision or otherwise prevent the taking of action based on the decision.
  5. The Commission is not to make a decision in proceedings concerning a dispute about weekly payments of compensation payable to a worker while a work capacity decision by an insurer about those weekly payments is the subject of a review under this section.
  6. A legal practitioner acting for a worker is not entitled to be paid or recover any amount for costs incurred in connection with a review under this section of a work capacity decision of an insurer.”

9. Applications to the Authority for Merit Review

Form of application – Section 44(2) 1987 Act

9.1 An application for merit reviewto the Authority must be made by the worker in the form approved by the Authority, available on the Authority’s website at http://www.workcover.nsw.gov.au. The form approved by the Authority for that purpose is the‘Work capacity – application for merit review by the authority’ form.

9.2 The application form must set out the grounds on which the Review is being sought and may attach any new or additional information relevant to the work capacity decision.

9.3 The Authority may declineto review a decision if the worker has not complied with section 44(2).

9.4 The worker does not need to attach to their application all of the existing documents and information relating to the claim or the work capacity decision, as the insurer will be required to provide all relevant information to the Authority as part of their reply to the application.

9.5 A worker may be assisted in completing the application form by another person such as the insurer, a support person, agent, union representative, employer, legal representative, orinterpreter.

(Note : Legal practitioners may not recover costs from a worker or insurer, see Clause 4.4 and 4.5.)

Multiple work capacity decisions or claims

9.6 An application may refer for review by the Authority more than one work capacity decision, about one or more of the worker’s claims, whether or not they are managed by the same insurer, however the time limit requirements must be met for each decision.

9.7 The Authority may determine whether or not such merit reviews of multiple work capacity decisions are most appropriately conducted together or separately as is appropriate in the circumstances of each particular case.

Exchange and lodgement of application by worker – Section 44(2) 1987 Act

9.8 Section 44(2) of the 1987 Act requires the worker to notify the insurer of an application for review by the Authority, in a form approved by the Authority. The form approved by the Authority for that purpose is the‘Work capacity – application for merit review by the authority’ form.

9.9 The approved form requires that the worker must send the insurer a copy of the form before, or at the same time as, lodging the application with the Authority.

9.10 The Authority may decline to review a decision unless and until the worker has complied with section 44(2) of the 1987 Act.

Time limit for lodging an application with the Authority – Section 44(3)(a) 1987 Act, Section 44(3)(b) 1987 Act

9.11 An application for merit review must be lodged by the worker with the Authority within:

9.11.1 30-days of receiving the internal review decision from the insurer; or

9.11.2 if the insurer failed to issue an internal review decision on time under section 44(1)(a) of the 1987 Act, within 30-days of the date that the insurer’s internal review decision was due,

noting that a work capacity decision is not stayed by any review process relating to that decision.Section 44(4) of the 1987 Act states:

(4) A review of a work capacity decision does not operate to stay the decision or otherwise prevent the taking of action based on the decision.”

Frivolous or vexatious applications – Section 44(3)(c) 1987 Act

9.12 The Authority may decline to review a decision at any stage of the merit review process if an application for review is, or becomes, frivolous or vexatious.

Declining to Review a decision

9.13 The Authority will notify the worker and insurer in writing if the Authority declines to review a decision under section 44(2) of the 1987 Act (approved form), section 44(3)(a) of the 1987 Act, section 44(3)(a) and (b) of the 1987 Act (time limit) or section 44(3)(c) of the 1987 Act (frivolous or vexatious).

9.14 If the Authority declines to review a decision the dispute has not‘been the subject of Merit Review by the Authority’as required by section 44(1)(c) of the 1987 Act. Under these circumstances, an application may not be made to the WIRO for procedural review until the Authority has been able to conduct a merit review.

Lodging an application with the Authority

9.15 The Authority will establish and maintain a registry for the referral of applications for review by the Authority. For the purposes of delivery or sending of documents for lodgement the address is:

Merit Review Service

WorkCover Authority of NSW
Level 19, 1 Oxford Street, Darlinghurst, NSW, 2010
Email: wcdmeritreviewservice@workcover.nsw.gov.au

9.16 Access may be made available to registered ECM users via password login to the Authority’s website address at http://www.workcover.nsw.gov.au.

9.17 Except on Saturdays, Sundays and public holidays, the registry is open to the public for lodgement of documents in person between 8.30am and 5:00pm. This clause is subject to clause 9.19.

9.18 The registry may make provision for lodgement of documents electronically and also outside the registry’s usual opening hours. Any documents lodged electronically after 5:00pm are deemed to be received on the next registry business day.

9.19 The registry may be kept open to the public for business or closed for business, at such times and on such days as the Authority shall determine.

9.20 The Authority will arrange for all applications made to the Authority under these Guidelines to be allocated a matter number and registered. All subsequent correspondence concerning the merit review application is to quote that matter number.

Exchange and lodgment of reply by insurer

9.21 A reply to an application for merit review must be lodged by the insurer with the Authority in the form approved by the Authority, as quickly as possible and preferably within 7 days of receiving the worker’s application. The form approved by the Authority for that purpose is the ‘Work capacity – reply to an application for merit review by the authority’form.

9.22 The reply lodged with the Authority must be submitted electronically via email or via the ECM system and must:

9.22.1 include a detailed list of all documents relevant to the work capacity decision and the Review of that decision, including documents supplied by the worker;

9.22.2 attach electronic copies of all of the documents included in the list of relevant documents, including documents supplied by the worker.

9.23 The insurer must first notify the worker of its reply to the application, by sending the worker a copy of the reply before, or at the same time as, lodging the reply with the Authority.

9.24 The reply provided to the worker must include the list of all relevant documents but does not need to attach copies of all the relevant documents being lodged with the reply. The insurer must provide the worker with copies of any of those documents which have not already been provided to the worker previously.

Surveillance images

9.25 Any surveillance images to be lodged with the Authority are to be provided by the insurer in DVD format and must first be provided to the worker. Any investigator’s or loss adjuster’s report concerning those surveillance images must also be provided with the images when they are provided to the worker and when lodged with the Authority.

9.26 If surveillance images have been provided by an insurer to a worker for the first time in support of a reply lodged with the Authority, the worker will be offered an opportunity to respond to the surveillance images.

9.27 Surveillance images held by the Authority are, where they contain personal information, subject to thePrivacy and Personal Information Protection Act 1998 (NSW).

Privacy

9.28 Merit reviews by the Authority are to be conducted in private and are not open to the public. Any decision, recommendations or statement of reasons are not available to the public. The Authority may however publish de-identified decisions, ensuring that the privacy of individuals is respected.

Note: An individual’s privacy should be respected. Failure to respect the privacy of an individual may result in a breach of thePrivacy and Personal Information Protection Act 1998(NSW) and/or theHealth Records and Information Privacy Act 2002(NSW).

The Authority recommends that no application, reply, decision, recommendation, or statement of reasons should be published, distributed or used in any way unless the privacy of all individuals referred to in the documents is respected, including the privacy of workers, their relatives, support persons, employers and their staff, insurers’ staff, officers of the Authority, legal representatives, medical practitioners, witnesses, interpreters, Internal Reviewers, Merit Reviewers, and any other individual person.

The Authority recommends that no such documents should be published, distributed or used in any way unless the express consent of any such identified individuals has first been obtained, or unless the documents have been thoroughly and sufficiently de-identified to ensure that the privacy of those individuals is respected.

10. Merit Review process and findings

Acknowledgement of worker’s application

10.1 The Authority will write to the worker and insurer as soon as practicable and preferably within 7 days of receiving the application for review to acknowledge receipt of the application and to:

10.1.1 explain the review process that will be undertaken;

10.1.2 confirm that a review of a work capacity decision does not operate to stay the decision or otherwise prevent the taking of action based on the decision;

10.1.3 confirm that the worker or insurer may provide any new or additional information relevant to the work capacity decision, after first exchanging that with the other party, and advising when that information is due to be received;

10.1.4 indicate when and how the decision will be conveyed to the worker and insurer.

Acknowledgement of insurer’s reply

10.2 The Authority will write to the worker and insurer as soon as practicable and preferably within 7-days of receiving the reply from the insurer to acknowledge receipt of the reply and to:

10.2.1 advise whether any further information is required from either of the parties for the purposes of the review; and

10.2.2 confirm that a review of a work capacity decision does not operate to stay the decision or otherwise prevent the taking of action based on the decision.

Exchange of Information by workers and insurers

10.3 Any information that the worker sends to the Authority, whether as part of an Application, in response to a request by the Authority, or otherwise, must be sent to the insurer before, or at the same time as, sending the information to the Authority.

10.4 Any information that the insurer sends to the Authority, whether as part of a Reply, in response to a request by the Authority, or otherwise, must be sent to the worker before, or at the same time as, sending the information to the Authority.

Merit Reviewer and findings – Section 44(3)(e) 1987 Act

10.5 The merit review by the Authority is to be undertaken by a person:

10.5.1 who was not involved in the making of the original work capacity decision or the internal review by the insurer; and

10.5.2 with the appropriate level of knowledge, expertise and skill relevant to the particular work capacity decision referred.

10.6 The Merit Reviewer may determine his or her own procedure, is not bound by the rules of evidence and may inquire into any matter relating to the review of the work capacity decision in such manner as they think fit. Merit reviewers are subject to the rules of procedural fairness.

10.7 The Merit Reviewer is to take such measures as are reasonably practicable to ensure that the parties understand the nature of the application, the issues to be considered and the role of the Reviewer as an independent decision-maker, and that the parties have had an opportunity to have their submissions and any relevant documents or information considered.

10.8 The Merit Reviewer is to act with as little formality as the circumstances of the matter permit and according to equity, good conscience and the substantial merits of the matter without regard to technicalities and legal forms.

10.9 The Merit Reviewer will take into account the workers compensation system objectives at all times.

10.10 The Merit Reviewer may reasonably require additional information from the worker or the insurer for the purposes of the review, which the worker and insurer must provide, under section 44(3)(d) of the 1987 Act.

10.11 If requiring additional information from the worker the Merit Reviewer should allow the worker no less than 7-days to supply any such information. The Merit Reviewer may decline to review a decision if the worker fails to provide information requested by the reviewer within the time allowed.

10.12 The Merit Reviewer is to consider all of the material substantively and on its merits as if the original work capacity decision had not been made, and is obliged to make findings that they think are more likely than not to be correct.

Recommendations to the Insurer – Section 44(3)(e) 1987 Act, Section 44(3)(g) 1987 Act

10.13 The Merit Reviewer may also make recommendations to the insurer based on their findings, which are binding on the insurer and must be given effect to by the insurer.

Notification of findings and any recommendations– Section 44(3)(e) 1987 Act

10.14 The Authority will write to the worker and insurer as soon as practicable and preferably within 30-days of receiving the application advising of the outcome of the merit review.

10.15 The notification of the decision must be in writing and will include:

10.15.1 details of the findings of the review;

10.15.2 details of any recommendations to the insurer based on those findings;

10.15.3 a statement of reasons which includes the following:

10.15.3.1 findings on material questions of fact, referring to the documents or other material on which those findings were based;

10.15.3.2 the Merit Reviewer's understanding of the applicable law and rules, including the legislation, regulations or guidelines;

10.15.3.3 the reasoning process that led the Merit Reviewer to the findingsand to any recommendations made.

10.15.4 advice to the worker about the availability of further review options including:

10.15.4.1 that the worker may make an application to the WorkCover Independent Review Officer (WIRO) for a review of the insurer’s procedures in making the work capacity decision, within 30-days after receipt of the merit review decision from the Authority (section 44(1)(c));

10.15.4.2 advice on where the worker can obtain the application form approved by the Authority under section 44(2); and

10.15.4.3 advice on where and how such an application is to be made.

10.16 The merit review findings and any recommendations to the insurer based on those findings do not replace either the original work capacity decision by the insurer, which is not stayed by any review process under section44(4) of the 1987 Act, and do not replaceany internal review decision by the insurer. Recommendations made by the Authority are however binding on the insurer and must be given effect to by the insurer, independently of the original work capacity decision and any internal review decision.

Legislative Notice requirements apply to new work capacity decisions

10.17 Where as a result of any recommendations to the insurer by the Authority, the Insurer makes a new work capacity decision, any relevant legislative notice requirements applicable to that new work capacity decision must be complied with by the insurer before they have effect, including the requirements of;

10.17.1 Section 54 of the 1987 Act regarding ‘Notice required before termination or reduction of payment of weekly compensation’. As section 54(4) of the 1987 Act requires the insurer to give notice personally or by post, the postal service rule is automatically invoked. The postal service rule (Section 76(1)(b) of the Interpretation Act 1987) requires an additional 4 working days notice to be provided after the notice was posted; and

10.17.2 Clause 21, Schedule 8 of the Regulation regarding ‘Notice of increase in weekly payments of compensation’ for ‘existing recipients of weekly payments’, that is an injured worker in receipt of weekly payments immediately prior to 1 October 2012.

Related Content

Contact Us

Email
contact@workcover.nsw.gov.au
Telephone
13 10 50
Media enquiries
4321 5474 or 0413 186 799