Notifiable and not notifiable claims - Medicare Compensation Recovery 011-15020000

Injury situation

Example of notifiable claims

Example of not notifiable claims

Transfer assignment to Program Management?

School accidents

• the school is insured against the accident which gave rise to the claim
• the school has an insurance policy that covers payment for medical expenses incurred by the injured person

• the school holds an insurance policy that does not provide for any payment of medical expenses, or only covers payment of medical expenses which are not eligible Medicare or nursing home benefits or residential and home care subsidies
• the school is not insured or indemnified in respect of the injury or illness, and is not required by law to be so insured or indemnified

If Program Support Officer (PSO) and Service Support Officer (SSO5) cannot give advice, escalate to Program Management.

Schools are not legally required to carry insurance for accidents. Therefore, any compensation payment arising from a school accident must be considered on its individual merits.

Loss of dependency and/or loss of consortium

• If any part of the settlement or judgment (separate or in conjunction with the claim for dependency or consortium) includes an amount paid that relates to compensation for injury or illness sustained by the dependants or spouse, for example, psychological
• If the dependants or spouse pursue a claim or a continuation of a claim for the deceased person's injury or illness under the estate of the deceased

• If for past and future loss of benefits, services and finances including companionship, love, affection, comfort, mutual services or sexual relations
• If in relation to a death benefit of the deceased spouse, including a payment to a spouse or injured person under a superannuation or life insurance policy the recipient has contributed to

If PSO and SSO5 cannot give advice, escalate to Program Management if it is unclear whether a claim is only for loss of dependency and/or loss of consortium.

Any compensation payment arising for loss of dependency or loss of consortium must be considered on its individual merits.

Criminal injuries compensation

If acceptance of the payment extinguishes the injured person’s legal right to claim compensation from the person who makes the payment.

Where a State or Territory Act specifically excludes medical costs, the claim is not notifiable.

If PSO and SSO5 cannot give advice, escalate to Program Management to determine if the claim is notifiable. May need Program Management to seek more details supporting the decision from the relevant State or Territory Act.

Sporting injuries

If PSO and SSO5 cannot give advice, escalate to Program Management.

Any compensation payment arising from a sporting injury must be considered on its individual merits.

Wrongful deaths

Usually, the result of an accident caused by the misconduct of another person or company e.g. wrongful death claims are lodged for:

• malpractice (for example, professional negligence by a doctor or health care worker)
• unsafe premises
• unsafe working practices
• unsafe machinery, operations or faulty equipment

Note: wrongful deaths are different to fatal injuries or criminal injuries.

If they include claims for medical services for the:

• deceased injured person
• family member making the claim

If the claim is not for personal injury. For example, the family or estate of a deceased:

• worker, who dies because of a car accident while driving a company vehicle, the estate may lodge a claim for wrongful death against the employer because the employer failed to maintain the vehicle in proper mechanical repair
• person, who was attacked in the car park of a shopping centre may sue the shopping centre management or owners for failing to provide adequate security in the car park

Note: a claim may be pursued under both Criminal Injury Compensation as well as wrongful death.

If PSO and SSO5 cannot give advice, escalate to Program Management if it is unclear whether a claim is for personal injury to either/both the deceased injured and/or a family member.

Ex-gratia payments

If a claim is pursued outside of or separate to the ex-gratia payment.

If the payment received is a true ex-gratia payment made voluntarily.

Examples include:

• Australian Government's Redress Scheme
• Victorian Government's Bushfire Support Fund

If PSO and SSO5 cannot give advice, escalate to Program Management.

Any correspondence noting an ex-gratia payment must be considered on its individual merits.

Transport Accident Commission of Victoria (TAC)

If the injured person lives outside Victoria, it could be an interstate claim (occurred in Victoria, or in another state with a Victorian registered vehicle). It would likely be proceeding under Common Law and would be notifiable.

If the injured person lives in Victoria, the claim is likely to be Medical Excess only and not notifiable.

If PSO and SSO5 cannot give advice, escalate to Program Management if it is unclear whether a claim is notifiable or not.

Insurance details not provided

Where the notifiable person is listed as an individual(s) contact the person submitting the request to ask for insurer details and/or requirement to be insured.

Register the claim if advised that the claim has:

• insurance but these details are not disclosed by the defendants
• no insurance, but the defendant is required to be insured, or
• unknown insurance details and unknown if required to be insured

As the claim progresses to settlement, the notification requirements should become clearer.

Where a company name or medical practitioner’s name is given as the notifiable person this can be accepted to register the claim if the request is signed by the notifiable person or their solicitor. Some large companies are self-insured.

Even if the notifiable person is an individual, group or company, a claim is notifiable, where they are:

• insured even if not required to be, or
• not insured but are required to be

Where there is more than one notifiable person, see Payments, refunds and debts.

If an individual is not insured and is not required to be insured.

If PSO and SSO5 cannot give advice, escalate to Program Management if it is unclear whether a claim is notifiable or not.

Workers’ compensation - redemption and permanent impairment payments

Australian state and territory workers compensation schemes can specifically preclude the payment of any medical benefits in relation to an injury or illness under claims made for incapacity.

Victorian legislation: A judgment or settlement for $5,000 or more is not compensation if the payment was made on or before 30 June 2006 under Subdivision 1, 2 or 3 of Division 3A of Part IV of the Accident Compensation Act 1985 (Vic) which includes the:

• Transport Accident Act 1986
• Workplace Injury Rehabilitation and Compensation Act 2013, and
• Accident Compensation Act 1985

Periodic payments from an income protection policy

Payments from sickness and accident insurance policies are looked at as ordinary income when the customer has paid or contributed to the premium. This includes income protection policies attached to superannuation policies. These are not notifiable.

If PSO and SSO5 cannot give advice, escalate to Program Management if:

• a Victorian workers compensation claim amount was fixed on or before 30 June 2006
• there is dispute over whether a workers compensation incapacity payment is notifiable or not

Overseas accidents and compensation payers located in Australia or overseas

If PSO and SSO5 cannot give advice, escalate to Program Management if it is unclear whether a claim is notifiable.

Any compensation payment arising from an injury sustained overseas or paid by an overseas payer must be considered on its individual merits.

Payment under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act)

The decision will state under which section/s of the SRC Act that the compensation amount has been awarded.

Where compensation is awarded for:

• Compensation for injury (section 14) This is a reimbursement arrangement, see section 16 below
• Medical expenses (section 16) - where medical treatment compensation is reinstated 6 months or more after the date of determination to cease medical treatment.
• Permanent impairment and non-economic loss lump sum compensation (section 24 and section 27)

Where compensation is awarded for:

• Injury resulting in death (section 17) and reimbursement of funeral expenditure (section 18)
• Medical expenses (section 16) - ongoing payments (but if ceased then reinstated 6 months or more later, payment is notifiable)
• Weekly incapacity compensation (section 19 to section 22) - ongoing payments
• Interim permanent impairment compensation (section 25)
• Household services and attendant care (section 29)
• Redemption of weekly incapacity lump sum (section 30)
• Rehabilitation costs (sections 36 and 37)
• Modifications, Aids and Appliances (section 39)

If PSO and SSO5 cannot give advice, escalate to Program Management if it is unclear whether a claim is notifiable.