A quick glance through the claim form received will indicate if any information is missing. It is important to identify those areas, as missing data in some places will affect the claim registration process on PRACSYS.
Some of the things to look for are:
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a medical certificate;
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whether the employer agrees with the claim;
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the claimant's signature, address and date of birth;
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•witness statements, or contact name/s and address/es where appropriate; and
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taking care to look at previous injury or illness history, and the day that the condition occurred (eg the day following the weekend). Fraud will always be a possibility and should never be discounted.
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Example |
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An employee had a simple unwitnessed neck injury, which she attributed to lifting a patient in late 1994. She noted on her claim form that she suffers from neck arthritis and has had several previous neck conditions, resulting in major surgery. |
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The claim is quickly accepted at 'face value', even though the medical certificate supplied with the claim indicates that the condition has resulted from “unknown origin”. |
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The condition determined encompasses the whole back area. |
So, is the employee's compensable condition the cause of all her ongoing back problems (now stretching down arms and legs), or has all her pre-existing neck history simply progressed along its natural path of degeneration? There is even strong doubt that there was an incident involving a claim for compensation.
While fictitious, this example demonstrates that, had this claim been investigated more thoroughly at the initial claim stage and tightly monitored, the total estimated liability for the claim would probably stand at less than $5,000.
At best, initial investigation should have resulted in short term acceptance of a temporary aggravation to the pre-existing neck injuries. The total claim cost would probably have involved a liable period of about a month, and then become inactive.
Footnote: Estimated liability for the claim may well exceed $550,000.
In this case, there was ample evidence on the claim form to warrant full investigation, to establish whether there was liability in the first place.
This demonstrates how important it is to examine a claim carefully at the outset. Overlooking, or not having regard to, valuable information at the claim receipt stage can cause some expensive and lengthy repercussions later on.