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Case Studies

6 February 2019 | Injured truck driver permitted to keep overpayment

An injured truck driver who was overpaid weekly workers compensation payments by his employer has been allowed to keep the money after he reached out to WIRO for help. The 50-year -old Western Sydney man had received three weekly payments for $1200 before it was discovered he was entitled to $500 a week. The injured man contacted WIRO after his employer proposed cutting off his future payments to recoup the money. When a WIRO team member spoke to the worker’s insurer, they admitted that instructions to the worker’s employer were, 'not as clear' as they could have been. WIRO suggested that given the injured worker was not at fault, recovery of the overpayment would not succeed in the Workers Compensation Commission, and the insurer should absorb the loss. The insurer agreed to reimburse the employer and instructed the trucking company not to recoup the funds.

If you have an enquiry about your claim, contact WIRO on 13 9476.

5 February 2019 | WIRO discovers injured Illawarra worker was underpaid.

A 36-year-old Illawarra woman who contacted WIRO after her insurer suggested she’d been overpaid, has discovered she'd been underpaid by $3,000. The woman approached WIRO after her insurer claimed that her Pre Injury Average Weekly Earnings had been determined to be $550 per week, even though she’d been receiving payments of $750 per week. PIAWE is usually calculated over 52 weeks, prior to an injury occurring, unless there are exceptional circumstances. The woman reached out to WIRO staff who found that a previous promotion hadn’t been factored into the payment calculation. WIRO forwarded confirmation of the promotion to the insurer and suggested an exception to the 52-week calculation period should apply. The insurer responded by paying the woman a shortfall of $3000, based on a new weekly payment amount of $1,000. ... If you have an enquiry about your claim, contact WIRO on 13 9476. 

31 January 2019 | Man receives travel expenses to collect severe pain medication

An injured worker living in Western NSW has been reimbursed travel expenses required to collect strong pain medication from a pharmacy 100km from his home. The worker attempted to claim $112 in travel expenses but the insurer denied the claim because travel expenses to purchase medication only are not generally compensable unless there are unusual circumstances. The worker contacted WIRO explaining that his doctor had closed his medical practice for 6 weeks over the Christmas holiday period, and the local pharmacist was restricted from providing all the pain medication at once. The injured worker had needed to make a second round-trip to fill his prescription during the holiday period. WIRO put the facts to the insurer, and the travel claim was paid immediately with the insurer agreeing to cover further travel claims under similar circumstances. If you have an enquiry about your claim, contact WIRO on 13 9476.

29 January 2019 | Insurer reconsiders carpark fall after WIRO intervenes

An insurer who denied an injured health worker’s claim after she fell in her employer’s carpark has reconsidered its position after the woman sought help from WIRO. The 55-year old Western Sydney woman was denied compensation because she had already begun her journey home. However, WIRO requested a case review and asked the insurer to consider the case of Smith v Woolworths Ltd (2017) NSWWCC 290, where it... was found that a worker injured in their employer’s car park, was not yet on a journey. WIRO suggested there were similarities between the matters and the insurer overturned the decision and accepted liability. If you have an enquiry about your claim, contact WIRO on 13 9476.

14 January 2019 | WIRO helps injured teacher with insurer payments

An injured teacher from Wollongong has had her weekly payments reinstated after a dispute with her insurance company over medical information. The 56-year-old woman did not receive payments for 9-weeks, following a request by the insurer for more information. Payments did not resume even after the injured worker provided an updated Work Capacity Certificate. WIRO contacted the insurer and payments were quickly reinstated. However, the insurer did not explain the delay. If you have an enquiry about your claim, contact WIRO on 13 9476.

3 January 2019 | An administration worker complained to WIRO that case manager would not reimburse future medical expenses for specialist consultations

An administration worker from Sydney complained to WIRO that their case manager would not reimburse future medical expenses in relation to specialist consultations. The case manager told the worker they had asked the specialist to invoice the insurer directly. At the worker’s next specialist appointment, the specialist’s administrator advised they had not received any billing instructions from the insurer. They demanded the worker pay the $360 fee upfront in order the keep the appointment and seek reimbursement from the insurer. The worker paid the fee and sent a request to the insurer for reimbursement. The case manager refused to pay and referred the worker back to the specialist. WIRO made an inquiry with the insurer. In response, it apologised and confirmed that nobody from the insurer had advised that particular specialist’s rooms of the billing procedure. The insurer reimbursed the worker immediately and provided billing instructions to the specialist’s rooms for use at subsequent appointments. Injured workers with enquiries about their claim may call WIRO on 13 94 76.

3 January 2019 | An injured worker was receiving incorrect payments

WIRO has resolved a compensation dispute for a 42-year-old Sydney woman, who had been injured at work and required wrist surgery.  The woman felt that her weekly compensation payments were incorrect, based on her pre-injury average weekly earnings (PIAWE.) The WIRO Solutions Group reviewed the calculation and found that the insurer had mistakenly based its payments on the income of a Queensland employee with a similar name. The insurer has reimbursed the injured woman $4,000 and her ongoing weekly payments have been increased by $400. Injured workers with enquiries about their claim may call WIRO on 13 94 76.

12 December 2018 | A worker underwent surgery and was off work for two months

A worker underwent surgery and was off work for two months. She complained to WIRO about the amount she was paid during those two months, that it was substantially less than her pre-injury earnings.​WIRO queried the PIAWE with the insurer. In response, it reduced PIAWE from around $980 to $920. The insurer provided WIRO with the wage information it had used to make its calculations.​WIRO reviewed the information and identified that the insurer had used payroll data for a different employee, one who had a similar surname to the injured worker but resided and worked in another state, resulting in a significant shortfall.When WIRO relayed this to the insurer and provided payslips from the worker, the insurer re-calculated PIAWE to be $1,500, resulting in a back payment of over $5,000 to the worker.If you have an enquiry about your claim, contact WIRO on 13 9476.

6 December 2018 | A financial services worker from the Blue Mountains submitted a quote for home modifications

A  worker submitted a quote for home modifications. She was wheelchair bound following her injury and needed a ramp built so that she could access her home without assistance from others. Her former scheme agent gave verbal approval for the claim but no written approval was completed before the claim was transferred to a new scheme agent. Therefore, the work had not commenced. The worker had not heard from the new scheme agent for some time and was having difficulty accessing her home. WIRO submitted an urgent inquiry. The insurer approved the modification within a day of receiving our email. If you have an enquiry about your claim, contact WIRO on 13 9476.

23 October 2018 | A clerk from south-west Sydney made a claim for psychological injury which was disputed by the insurer

A clerk from south-west Sydney made a claim for psychological injury which was disputed by the insurer. He sought some documents relied upon by the insurer in relation to his disputed claim, but the insurer refused to pass these on to the worker. The insurer cited Clause 41 of the Workers Compensation Regulation 2016 believing that supplying the documents could cause harm. WIRO contacted the insurer also citing Clause 41 and it was agreed the outstanding documents would be sent to the worker’s GP. The insurer also agreed to fund one further consult for the GP to explain and provide the outstanding documents to the worker. If you have an enquiry about your claim, contact WIRO on 13 9476.

18 October 2018 | A nurse employed at a hospital on the south coast of NSW complained that the insurer had miscalculated her PIAWE

A nurse employed at a hospital on the south coast of NSW complained that the insurer had miscalculated her PIAWE. WIRO requested a copy of the insurer’s calculations. After receiving a spreadsheet from the insurer, we identified that the insurer had included seven weeks of leave without pay in the relevant period and that shift and overtime allowances had not been included. The insurer directed our concerns to the employer who was making weekly payments. After explaining the process for determining PIAWE, the worker’s weekly benefit was increased from around $800 to around $1,100 per week. The worker also received a payment for past under payments. If you have an enquiry about your claim, visit https://wiro.nsw.gov.au/injured-workers/complaints-and-enquiries or call 13 9476.

11 October 2018 | A retail worker from Sydney made a claim in June 2018 for an injury sustained in November 2017

A retail worker from Sydney made a claim in June 2018 for an injury sustained in November 2017. Initially, the claim was reasonably excused, before liability was accepted in August. The worker complained he had not received weekly payments. In response WIRO’s inquiries, the insurer advised there had been a further hold up as the employer had challenged their decision to accept liability. The insurer conducted a review and confirmed their decision to accept the claim in September. WIRO requested the insurer to process payments without further delay. In response, the insurer stated they processed payment to the employer but that one week’s entitlement had been withheld, being the excess for late lodgment of claim.

WIRO referred the insurer to the SIRA document When a worker is injured: A workers compensation guide for employers which states, “If you do not report the injury within five calendar days, you may pay a ‘claims excess payment.” In other words, the employer is penalised the excess, not the worker. WIRO asked whether the employer had paid all entitlements to the worker. The insurer replied that the employer had processed payment of nearly $9000, which covered the entire period of incapacity.  If you have an enquiry about your claim, contact WIRO on 13 9476.

5 October 2018 | A worker’s lawyer complained that their client had made a claim for hearing aids but had not received a response

A worker’s lawyer complained that their client – a 48 year old plumber from northern NSW – had made a claim for hearing aids on 15 August 2018 but had not received a response. Prompted by WIRO’s enquiry, the insurer contacted the worker directly to ask him if he would really wear the hearing aids. The worker reported this to his lawyer who complained it was not appropriate to contact the worker directly to ask a question of this nature. WIRO suggested the fact a claim was made should satisfy the insurer. The insurer apologised and then approved the claim for hearing aids. If you have an enquiry about your claim, contact WIRO on 13 9476

28 September 2018 | A worker complained the insurer was not paying weekly benefits for a period the worker took extended leave despite an award from the Commission

A worker complained the insurer was not paying weekly benefits for a period the worker took extended leave despite an award from the Commission. The insurer cited the employer’s handbook which stated that workers can be paid extended leave if they exhaust sick leave. The insurer would not deviate from the employer’s view that the extended leave should be treated like sick leave. WIRO referred to s49 and s50 of the 1987 Act and suggested the type of leave taken was more important than the reason it was taken. This was escalated to more senior representatives at the insurer, who confirmed weekly payments would be paid in addition to extended leave. If you have an enquiry, call WIRO on 13 9476.

6 September 2018 | Lawyer complained that client’s claim for hip replacement surgery from June 2018 had not been determined by insurer

A lawyer complained that their client’s claim for hip replacement surgery made in June 2018 had not yet been determined by the insurer. WIRO asked the insurer to explain why the claim had been delayed for so long. The insurer replied that the treating surgeon indicated in their report that the worker should think of delaying the hip replacement surgery if he could. However, the insurer never issued a dispute notice setting out that position. Consequently. the insurer approved the claim for surgery within one day of WIRO’s inquiry. If you have an enquiry about a claim, contact WIRO on 13 9476.

30 August 2018 | An insurer wrote to an injured worker whose weekly payments had ceased due to Section 39

An insurer wrote to an injured worker – whose weekly payments had ceased due to Section 39 – advising she was overpaid $4000 in travel expenses “due to a number of different reasons…that is no one particular person’s fault”. The insurer proposed reimbursing 50% of future travel entitlements until the overpayment was recovered. The worker unsuccessfully objected to the proposed recovery noting the overpayment was caused by the insurer’s administrative oversight.  WIRO made its own inquiry with the insurer asking them to review the correspondence and reconsider the recovery. The insurer replied to WIRO that they agreed to waive the overpayment. If you have an enquiry, contact WIRO on 13 9476.

22 August 2018 | An insurer reasonably excused a claim for weekly payments

The worker had yet to make a claim but the insurer promised they would decide on liability within 10 days of their independent medical examination. It hadn’t, several weeks went by and so the worker contacted WIRO. We suggested he complete a claim form so the insurer would be compelled to determine the claim within 21 days. At the same time, we asked the insurer about the promise it had made to the worker about determining the claim after the examination. In response, the insurer confirmed the claim was accepted and the worker was back paid around $10,000. If you have an enquiry about your claim, contact WIRO on 13 9476.

16 August 2018 | An injured worker was overpaid and later made redundant.

An injured worker was – due to mistakes by her public-sector employer and the insurer – overpaid a total of around $1500 in weekly payments over several weeks. Later, she was made redundant and the employer’s payroll department deducted that amount from the worker’s final pay. The worker complained to WIRO who contacted the insurer. They said they were aware of an overpayment but unaware a deduction had been made from the worker’s termination payment. The insurer acknowledged they must wear the error and advised they would be in contact with the worker to have the deducted funds repaid. If you have an enquiry about your claim, contact WIRO on 13 9476.

10 August 2018 | A worker was certified fit to work 8 hours per week.

Before her injury, she was employed to work 35 hours per week. In June, she underwent surgery for a non-compensable injury. Her weekly payments stopped and she was paid sick leave for five weeks. WIRO inquired with the insurer who confirmed weekly payments had ceased in error. The insurer instructed the employer to pay sick leave for the 8 hours per week she could not work due to surgery and pay workers compensation for the remaining hours, for which she was unfit regardless of the surgery. The worker’s sick leave was recredited by her next pay period. If you have an enquiry about your claim, contact WIRO on 13 9476.

6 August 2018 | A worker complained PIAWE was incorrect

The insurer calculated PIAWE at around $410. After WIRO’s initial inquiry, the insurer reduced PIAWWE to $390. The insurer based their decision on a “payroll summary” the employer provided. WIRO told the worker to request a review. In the meantime, we suggested the insurer obtain payslips to calculate PIAWE as they show gross earnings broken down among various types. The insurer obtained additional income details from the employer and the PIAWE was increased to $460, obviating the need for a review. The worker was back paid around $1300.00. If you have an enquiry about your claim, contact WIRO on 13 9476.

26 July 2018 | A worker had two concurrent claims managed by one scheme agent

The agent reduced PIAWE, after which the employer pursued the worker for alleged overpayments she received whilst the higher PIAWE applied. The worker complained to WIRO about the alleged overpayment and the revised PIAWE calculation. WIRO reviewed the matter and it appeared the calculation was too low. WIRO referred the scheme agent to Icare’s PIAWE handbook as well as Schedule 3 of the 1987 Act. In response, the insurer agreed that there was no overpayment, but rather a $6000 underpayment. The worker was back paid and PIAWE increased by around $300. If you have an enquiry about your claim, contact WIRO on 13 9476.

19 July 2018 | A worker from Walgett broke his tibia and fibula

He relied on his daughter, who resides in Dubbo to drive him to his specialist, who was also in Dubbo. This required one round trip to Walgett to collect the worker and another to get him home.  The insurer refused to pay for two round trips and suggested the worker take the bus. WIRO made representations to the insurer noting the type of injury and dearth of travel options, suggesting it was not appropriate to catch a bus with such an injury and the locations involved. The insurer then confirmed they would pay all round trips required. If you have an enquiry about your claim, contact WIRO on 13 9476.

13 July 2018 | A worker complained to WIRO that his PIAWE of $464.35 was too low

The insurer’s original decision relied on 52 weeks of prior earnings, even though the worker had recently been promoted to full time work. WIRO suggested they review the relevant period. In response, the insurer increased PIAWE to $676.35. However, this new calculation also included weeks of work after the date of injury in the relevant period. WIRO suggested the insurer take a third look at PIAWE and exclude periods after the date of injury. PIAWE was increased again, this time to $732.62. The worker was back paid for past shortfalls in entitlements. If you have an enquiry about your claim, contact WIRO on 13 9476.

5 July 2018 | A worker received a letter from his insurer saying weekly payments would reduce to $1330 after 52 weeks

He was confused because his gross payments from his employer were $1000.  The insurer told WIRO the worker should contact his employer to discuss a shortfall.  WIRO replied it was the insurer’s duty to confirm the employer was passing on the correct weekly payments.  The insurer subsequently investigated and found the worker was underpaid nearly $40,000.  The insurer confirmed the employer would be contacting the worker to reimburse the worker for its underpayment. If you have an enquiry about our claim, call WIRO on 13 9476.

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