Insurer Report

The Spring 2010 issue of the Insurer Report outlined some examples where workers have a right of review following certain Medical Assessment Tribunal Decisions relating to claims where insurers make decisions to cease claims based on information from the tribunals' findings but not the actual decision of the tribunal.

 

In future compliance audits, claims ceased following a MAT hearing will form part of the targeted component of the audit sample.

 

We will be looking to ensure that workers have been advised of their review rights in these cases.  We will also be looking to ensure that workers' rights regarding this issue are covered in your claims procedures manual.

 

Examples of a right of review

 

An example of where there is a right of review is when a worker is referred to the MAT for assessment of permanent impairment, (section 505) and the tribunal finds there is no permanent impairment.  However the tribunal has not decided that there is no ongoing entitlement to compensation.

 

The insurer may decide on the basis of the information in the tribunal findings, and other information it may have on file, that the worker no longer has an injury under the Act and decide to finalise the claim.  This is the insurer's decision and the worker still has a right of review.  If there is information in the tribunal findings in support of this position then there is a high likelihood that if reviewed, the decision will be confirmed.

 

Another example is if a worker is referred for the tribunal to assess incapacity for work but has not been asked to assess permanent impairment (section 502).  The tribunal finds the worker does not have an incapacity for work. The insurer then decides to cease the claim because of no incapacity for work and no requirement for medical treatment.  The tribunal decision supports this decision in relation to the incapacity for work but not necessarily the medical treatment.  It is the insurer's decision to cease the claim and that decision to cease is reviewable by Q-COMP.

 

Examples of where there is no right of review

 

• A worker is referred for assessment of injury under section's 501 or 503 and the tribunal finds that the worker does not have an injury.

 

• Tribunal finds the worker has a permanent impairment and the insurer issues a notice of assessment on the basis of that decision (section 502 and 505).  The usual provisions about the response to the offer and the ending to the claim apply.  Given the PI decision is made by the MAT and there is no discretion for the insurer in how it responds under the Act (sections 185 & 190).  There is no right of review.