While risk management can minimise the risk of injury, the possibility of zero injuries occurring indefinitely, is remote. Therefore despite our best endeavors there will always be injuries that become claims. The size of the claim and the way in which it is managed has a direct bearing on future insurance premiums.

Claims fall into two categories: Significant and Non-significant

1. Non-significant claims - where the worker is off work for 5 days or less.
2. Significant claims - where the worker is off work for more than 5 days. These are the claims that must be proactively managed by the employer to achieve the best possible outcome.

Insurers and employers, for a multitude of reasons, have failed to manage significant claims proactively and this has created unprecedented scope for improvement. This is precisely where our systems will produce major reductions in the duration and subsequently, the size of significant claims, directly reducing premium loadings.

All stakeholders will benefit directly.

• The worker.
• The employer.
• Service providers – rehabilitation, medical and various services for early resolution of the claim.
• The insurance company or claims agents as agents of WorkCover.

Other factors or considerations that may impact on claims

• The worker who needs to understand their obligations and know that they are part of the claim procedure (and that the employer is interested in them).
• The employer, who must be proactive and manage all aspects of the injury, the claim and return to work so that early settlement of the claim is achieved .
• Service providers if they are to be truly effective, must work together as a team towards a healthy and early return to work . Each must collaborate and integrate their medical and practical solutions seamlessly into one plan.
• The insurance company or claims agent , who must administer the team plan ensuring stakeholders responsibility and activity. It is the insurer or claims agent who takes the financial governance role in balancing claims costs and providing efficient injury and claims administration. This custodial role dictates that the insurer or claims agent honour their responsibilities to each of the stakeholders.

The system includes unique key control points some of which are: -

1. Educating the employer that aggravation of a pre-existing condition constitutes a legitimate claim. It is therefore imperative that employers ascertain knowledge of any pre-existing conditions so that they can adjust the duties of the employee, even before employment commences.
2. Employees understanding that the employer bears the costs with respect to their claim and the impact it has on the profitability of the company (workers compensation is not a Government funded benefit).
3. The rehabilitation provider - The sequence of assessing the claim: -
   • Speed is essential. Dedicated call centres are set up in the rehabilitation providers office, manned 24 hours a day by experienced assessors. They will determine initially whether the claim falls into significant or non-significant status. An assessor will, at the time of this phone call, complete the claim form on your behalf and also notify the insurance company or claims agent.
   • Significant claims (5 days or more).
     All injured workers are interviewed at the employers’ premises, by appointment and generally within 48 hours or less . This interview is carried out by an assessor from the rehabilitation provider with the sole purpose of achieving the best outcome possible. The assessor needs to achieve certain objectives: -
     • Inspect the accident site to see whether a dangerous situation exists and also whether the accident has been caused in the way reported.
     • Build goodwill between employer and employee.
     • Make the employee aware of the costs of the claim on the company.
     • Set up a back to work plan in consultation with the employer and the employee
     • If necessary the assessor will organise a further medical with a sports medicine specialist. It has been estimated that up to 90% of all workers compensation claims relate to the muscular skeletal system and this is traditionally the area of expertise where sports medicine doctors excel.
     • The assessor will then give his report to the insurance company or claims agent.

4. The insurance company/claims agent , if they wish to participate in our system, must meet our strict criteria

• To appoint a designated team of case managers and staff.
• To provide excellence in communication, relevant and timely information to all stakeholders.
• Most importantly to always liase and keep the employer informed.

It is the employer who pays workers compensation premiums. It is professional and timely advice that enables the employer to best manage the outcomes.

Key Partners - Structural elements

Insurers & Claims Agents

Because the integrity of our system relies upon our partners’ ability integrate efficiently and effectively, we will only allow those insurers and claims agents who have a proven track record of performance to participate in our scheme. We require designated teams to be appointed to our clients to ensure fast tracking of service and claims support. Claims must be reimbursed quickly and fairly.

The providers ability to correctly set claims reserves, liase with stakeholders and finalise the claim is vital because wrongly reserved claims cause excessive premium loadings and unless challenged early, premium overcharging can not be refunded.

Therefore, only those parties with a national focus on client service and who are solid financial institutions are permitted to participate in our system. .

Injury Assessors

Critical to the effective management of loss, is the ability to instantly identify and evaluate the seriousness of injury. Injury assessment is not the responsibility of the insurer or clams agent. They simply control premium charging and the claims paying service functionality. Our system for this activity requires a dedicated support team of specially qualified injury assessors to evaluate and make immediate decisions on injury treatment. Our partners here are industry leaders who helped pioneer our system. Specialist in sports injury medicine, their skills have been honed and applied to our system requirements. Our clients have access this facility via a 1300 hot line 24 hours a day, 7 days a week.

Our assessors immediately assess the injury and decide whether it represents a significant or potentially significant injury. They will also complete the claims advice for the insurer or claims agent and handle the entire procedure. If necessary an on site employee employer meeting may be arranged within 48 hours where claims warrant this. The injury is totally managed from the initial report to the medical treatment and return to work.

Occupational Health & Safety Consultants

While many businesses know this is compulsory in all states and have OH&S policies, many fail to have documented processes and systems in response to the legislation. Merely having an OH&S policy pasted up on the company staff room wall will not meet the legislative standard, particularly when a death may have occurred!
OH&S compliance is not just a strict legislative requirement but good risk management as well. Being able to identify what can go wrong, how can it go wrong and what can be done before it does go wrong, is the only way for business to operate today. Good OH&S strategies not only save premiums, but may help avoid significant fines, legal expenses and costs (not to mention keep you out of goal!).

You would also know that OH&S law is negative law, that is you need to prove you did not commit an offence. With the Corporations Act prohibiting directors and officers from funding defence costs for themselves out of company finances, this is no place for ignorance of the law or the faint hearted. Hold on to your house, and the shirt off you back by risk managing your exposure here.

Our partners are key provisioners in OH&S services and their qualifications makes them pre-eminent in their field. With experience in WorkCover prosecutions, audits, self-insurance and litigation they are your “get out of goal free card”

Pre-employment medicals providers

Part of any risk process is the identification of risks to be managed. In this system element, our partners specialize in the business of identifying those employees who are not fully capable of performing the tasks set them due to physical limitations or potential to sustain injury. In addition comprehensive medical examinations can and do reveal pre existing injuries or injuries that may be aggravated by the nature of the work to be performed. Completion of pre-employment medicals can avoid the risk to an employer of being saddled with an aggravated injury claim on his workers compensation insurance policy.

Our partners in this system element are specialists of long standing.

Legal Advisors

Because complex claims and complex injuries do arise, it is crucial to have the best expertise on call. In cases where there are fatalities, evidence is taken by WorkCover inspectors and this evidence is prima face evidence used against the employer. Issues will be considered by the insurer or claims agent such as whether the employer has a valid claim for indemnity or are there civil and criminal proceedings that may flow from this same accident. This is not the time to ring your mate to see if he knows a good lawyer.

Our partners will also, if required, become involved in the setting and verification of claims estimates since as previously mentioned, an incorrect or incomplete estimate can result in additional premiums being charged.

Workers compensation authorities are required to not only police the compensations acts, but also the OH &S Acts and regulations. In many statutes now these acts have been modified to include criminal prosecution, with the provision for very large fines for individuals including potential goal terms for directors or principals.

Our partners are industry leaders in legal advice and service for workers compensation and OH&S. With publications, presentations and key support services, they are unique elements in our system.

Together with our risk insurance strategies, your personal legal costs, your company legal costs, the cost of fines and penalties and even the legal costs imposed on you for WorkCover’s costs can be covered.

All this and more is part of our total risk and insurance solution for you.

Premium payment providers

Premiums can be a significant strain on your finances. While most providers allow installments, invariably premium claims loadings, premium disputes, timing issues and unexpected cash shortages all take their toll when things get out of whack.

We recognize these all add to the cash flow constraints for your business and if there is one slow debtor, then the domino’s can tumble.

We have arranged for our clients a funding facility allowing pay by the month with very attractive rates and absolutely minimal security required. Don’t deplete your overdraft facility.

By utilizing the premium funding option, you can even out the highs and lows in your revenue cycles, allowing you to deploy your capital to more beneficial arrangements such as generating more sales, increased production or additional business/investment opportunities. And you bank manager will never know – its off balance sheet financing at it’s best!