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Case Studies

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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