readers guide to the insurances purchased by the ......10 july 2015 1 january 2016 original version...
TRANSCRIPT
* ParentsNext and Transition to Work Providers must refer to the Provider Portal for Insurance information
Readers Guide to:
The insurances purchased by the department of employment, skills, small and family business for participants undertaking approved employment activities in jobactive
For:
jobactive Providers
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Effective Date: 1 July 2019
Index Document change history 3
Introduction 5
Insurances purchased by the Department of Employment, Skills, Small and Family Business 5
Who and what is covered? 5
What happens when a participant is injured? 6
Provider responsibilities 7
When must an incident be reported? 8
Insurance broker responsibilities 8
Accident and health international underwriting pty ltd (group personal accident insurer) responsibilities 9
Personal accident insurance 9
What is covered by the policy? 9
What is NOT covered by the policy? 10
Age limits for coverage 10
What medical costs are covered? 10
What medical costs are not covered? 10
Reimbursing Medicare ‘gap’ and other expenses through the Employment fund 10
Limitations of EF reimbursement 11
What are the major policy exclusions? 11
Combined (public and/or products) liability 12
What is covered? 12
What are the major exclusions? 12
What to do when a Third Party is injured or has their property damaged 12
Host combined (public and/or products) liability 13
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Effective Date: 1 July 2019
Document change history Version Start date Effective date End date Change and location
1.0 30 June 2015
10 July 2015 1 January 2016
Original version of document
1.1 1 January 2016
1 January 2016 27 June 2016 Changes to expand the Medicare ‘gap’ and out-of-pocket expenses to all participants, updates to the exclusions for the Group Personal Accident and Combined Liability Insurances and changes to the Capital Benefit for Death for under 18 year olds.
1.2 27 June 2016
27 June 2016 5 December 2016
Updates to the exclusions and inclusion of new activities for the Group Personal Accident and Combined Liability Insurances for participants.
Remove attachment A and B (claim forms) from this document, as they are available individually on the portal.
2.0 5 December 2016
5 December 2016 31 March 2017
Updates to the incident reporting process for Group Personal Accident Insurance claims and minor policy changes, including Capital Benefit for Death for under 18 year olds and watercraft exclusions for Combined Liability Insurance for participants.
2.1 1 April 2017 1 April 2017 30 June 2017 Inclusion of two new activities: Employability Skills Training and PaTH Internships.
3.0 30 June 2017
30 June 2017 2 February 2018
Updates to Capital Benefit for Death for under 18 year olds. Inclusion of Launch into Work Pilot, NEIS Training, and Exploring Being Your Own Boss Workshops. Removal of drug and alcohol exclusion in line with the insurance policy coverage.
3.1 2 February 2018
2 February 2018 30 June 2017 Updates to reflect department name change and to remove Work for the Dole Coordinator references.
4.0 1 July 2018 1 July 2018 Updates to reflect change of insurer for the Group Personal Accident Insurance for participants. Inclusion of new activities: Empowering YOUth Initiatives, Transition to Work, ParentsNEXT, Regional Employment Trial, Career Transition Assistance, Stronger Transitions.
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Effective Date: 1 July 2019
Version Start date Effective date End date Change and location
5.0 6 July 2019 1 July 2019 Updates to reflect change in insurer from Dual Australia to Accident and Health International and to reflect new incident reporting process.
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Effective Date: 1 July 2019
Introduction This Reader’s Guide (Guide) describes the insurance policies the Department of Employment, Skills, Small and Family Business (department) purchases for participants in approved activities in jobactive and Host Organisations delivering Work for the Dole – Community Support Projects.
This Guide also provides the insurance process and procedure requirements for jobactive providers (Providers). This Guide is not a stand-alone document and does not contain the entirety of Providers’ obligations. Please read it in conjunction with the jobactive Deed 2015–2020 and any relevant Guidelines or reference material issued by the department under or in connection with the Deeds.
This Guide is not a substitute for the insurance policies as it does not reflect all terms, conditions, exclusions and limitations of the actual insurance policies, it provides an outline of the coverage in force. Please refer to the insurance policy documents available on the Provider Portal for the actual terms and conditions.
Disclaimer: If there are any discrepancies between this Guide and the insurance policy documents, the insurance policy documents take precedence.
Insurances purchased by the Department of Employment, Skills, Small and Family Business
• Group Personal Accident Insurance – covers participants that injured whilst participating in approved activities in jobactive including travel to and from such activities.
• Combined Liability Insurance – covers participants’ liability arising from their negligence that cause personal injury to third parties or damage to third parties property, whilst participating in approved activities in jobactive.
• Combined Liability Insurance – covers owners and land lease holders of Private Property and Farms where their own public liability insurance does not provide for circumstances involving participants participating in Work for the Dole – Community Support Projects.
Who and what is covered? The Department’s insurance covers participants in approved employment assistance programs.
Note: Participants registered under Disability Employment Services (administered by the Department of Social Services) or the Community Development Program (administered by the Department of the Prime Minister and Cabinet) who participate in the above approved activities, are covered by these insurance policies.
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What happens when a participant is injured? The following tables describe what should happen when a participant is injured. It may be necessary to deviate from this process to ensure participants are supported and to allow providers to meet incident notification timeframes under the jobactive Deed 2015 – 2020.
Table 1 Initial Phase: Incident occurs 0–2 Hours
Who Requirements/processes
Participant Reports the incident to their supervisor and/or provider
Host/employer Help the participant:
• Make sure they are safe and comfortable • Offer first aid • Contact emergency services (if needed) • Contact the participant’s provider
Host/employer Complete the incident report form:
• Records all details of the incident, and • Supplies the form to the provider
Table 2 Day 1: Within 24 hours
Who Requirements/processes
Provider Report the incident to the department by recording the incident in the WHS Incident screen in ESS Web.
Note: A reference number will be provided on submission. Please contact [email protected] if a number is not provided.
Department Reviews the incident report and any additional information submitted:
• Follows up with the provider to address any concerns raised by the incident
• Reports incidents to the department’s broker and insurer • Supports providers with insurance processes
Table 3 Ongoing support: Day 2
Who Requirements/processes
Provider Support the participant:
• Review the incident form and have the participant sign it (if possible)
• Advise the participant to seek treatment from an appropriately qualified professional
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Who Requirements/processes
• Provide the participant with a copy of this guide and explain how and what they can claim from insurance
• Assists participant to complete insurance paper (as necessary) • Offer Medicare gap fee coverage from the Employment Fund (as
necessary)
Participant • Seeks medical treatment (if required) to assist in recovery • Retains receipts and seeks reimbursement of costs from Medicare • Submits an insurance claim if they are out of pocket in relation to
the injury.
Note: the Provider will help the participant if they require assistance with the claim form or with the insurer in general
Insurer Considers the participants claim and relevant information:
• Assessed claim and evidence supplied by the participant • Advises the participant of outcome including claim processes and
insurance coverage and limits (as necessary) • Reimburses eligible medical expenses in accordance with the policy
and evidence supplied by the participant/provider.
Provider responsibilities ‘Provider’ means the employment services provider contracted under the jobactive Deed, and includes its Personnel, successors and assigns, and any constituent entities of the Provider’s organisation, and includes reference to a Tendering Group contracted under this Deed, where applicable.
Providers are responsible for:
• Directing participants to the ‘Participants in employment assistance programs – A Guide to your Insurances’ (Participant Insurance Guide) before they commence in an approved activity. The Participant Insurance Guide is located on the department’s webpage or on the Provider Portal.
• Adhering to insurance arrangements and incident management procedures outlined in this Reader’s Guide and in the Deed and Guidelines.
• Reporting any incidents and/or near misses that occur to the department and Gallagher as soon as practicable and within 24 hours as per the Deed and Guidelines, including updating incident information as required.
• Reporting ‘notifiable incidents’1 that occur in their workplace to their jurisdiction’s Work Health and Safety Regulator. ‘Notifiable incidents’ may relate to any person—whether an employee, contractor or member of the public. Providers must advise their Account Manager immediately
1 https://www.safeworkaustralia.gov.au/doc/incident-notification-fact-sheet
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of such an event and advise if the incident has been reported to the relevant Work Health and Safety Regulator.
• Supporting and assisting participants to submit insurance claims.
• Supporting and assisting Gallagher and (for participants accidents/injury) AHI and the department upon investigation of insurance claims.
• Educating themselves on work health and safety legislation applicable in their jurisdiction.
When must an incident be reported? The Provider must notify Gallagher and their Account Manager within 24 hours of any incident and/or near miss occurring during an approved activity, including those:
• that result in accident, injury or death of:
o any participant (including where the incident occurs while the participant is travelling directly to and from an Activity)
o any Personnel involved in the delivery or supervision of the approved activity, or
o members of the general public.
For all work health and safety incidents Providers must notify the department via the WHS Incident screen in ESS Web. For incidents resulting in personal injury to third parties, damage to third party property or Community Support Projects, Providers must submit an incident form to [email protected].
Incident notification forms are available on the Insurance page of the Provider Portal.
The incident report must identify whether the incident was caused by an instance of misconduct by a participant. Misconduct is defined as being something that would, if the participant was a paid employee, normally result in the paid employee being terminated from paid employment.
Note: The participant is not required to sign the incident report form if they do not wish to. If an insurance claim is made the insurer may request this at a later stage.
Insurance broker responsibilities The department contracts an insurance broker, Arthur J Gallagher (Gallagher) to manage its insurance arrangements for participants and Host Organisations and to assist Providers and participants as required.
Gallagher is responsible for:
• liaison, negotiation and placement of the insurances with appropriate insurers
• providing professional insurance advice to the department for participants in relation to these policies.
Providers should contact their Account Manager or the department at [email protected] if they have queries in relation to insurance policies or require assistance with completing an incident or claim form.
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Accident and health international underwriting pty ltd (group personal accident insurer) responsibilities Accident and Health International Underwriting Pty Ltd (AHI) is the insurer of the Group Personal Accident Insurance Policy for participants, from 1 July 2019.
AHI is responsible for:
• providing insurance, and
• processing insurance claims.
Accident and Health International Pty Ltd
Email: [email protected]
Note: all general insurance queries and questions should be directed, in the first instance, to the department. AHI should only be contacted in relation to individual claims submitted by/for participants. Dual Australia is the insurer for incidents that occurred between 1 July 2018 and 30 June 2019. QBE Insurance is the insurer for incidents that occurred prior to 1 July 2018. Contact details for Dual and QBE are available through the department.
Personal accident insurance
What is covered by the policy?
This insurance policy provides cover to participants for an injury or death that occurs while participating in approved activities including direct travel to and from such activities.
Travel includes:
• from the participant’s home to the approved activity
• between approved activities
• during the approved activity
• between the Provider’s location to the approved activity and vice versa.
“Injury” means bodily injury resulting from accident and which is not an illness and which:
(a) occurs during the period of insurance, and on or after the insured persons effective date of individual insurance
(b) occurs within 12 months of the injury, results solely and independently of any other cause (such as any pre-existing physical or congenital condition) in the events covered under this policy, and
(c) includes any condition resulting from exposure to the elements whether as a result of injury or not.
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What is NOT covered by the policy?
• This policy will not pay doctors’ bills or hospital bills or other medical accounts that are recoverable under Medicare.
• This policy will not pay for any balance of monies due or payable after deduction of any Medicare benefit, commonly referred to as the “Medicare Gap”.
• The Personal Accident Policy is not a workers’ compensation policy. Participants in the approved activities covered by this policy do not qualify for workers’ compensation.
Where a participant does incur ‘gap’ expenses, reimbursement of these expenses may be permissible. See section ‘Medicare ‘gap’ and out-of-pocket expenses’ below for further information.
Age limits for coverage
This policy covers insured persons up to 70 years of age.
What medical costs are covered?
Reimbursement for costs certified necessary, by a legally qualified medical practitioner, and incurred within twenty four (24) months of the participant sustaining injury, for medical expenses and treatment following an accident, do not attract a Medicare rebate. Such costs include:
• ambulance service, operating theatre fees in a private hospital, bed/room charges in a private hospital, chiropractor, physiotherapist, osteopath, naturopath, masseur, nurse or similar provider of medical services.
What medical costs are not covered?
Costs that attract a Medicare rebate are not covered. For example, medical bills from doctors, surgeons, anaesthetists, pathologists, drugs or medicinal preparations that form part of an ancillary health benefit pursuant to the Health Insurance Act 1973. Participants should submit these bills to Medicare for reimbursement, in the first instance and seek reimbursement for outstanding expenses from their provider, see below for more information.
Cost of dental treatment is also excluded under the policy, unless such treatment is necessarily incurred to sound and natural teeth, excluding dentures, and is caused by injury directly related to the incident.
Reimbursing Medicare ‘gap’ and other expenses through the Employment fund
If a participant incurs an expense as a result of an injury not covered by Medicare or department’s insurance, the participant may claim through the provider’s insurance. If the provider’s insurance cannot pay these expenses, reimbursement may be claimed through the Employment Fund (EF).
Reimbursement of ‘out of pocket’ expenses through the EF is made on a case-by-case basis, it is not automatic.
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The process to reimburse these expenses is as follows:
1. Participant receives and pays for medical treatment and claims any reimbursement from Medicare.
2. If there is a ‘gap’ the participant submits evidence of payment and the ‘gap’ to their Provider for consideration.
3. The Provider ensures the relevant information has been provided to support the claim and pays the participant and then seeks reimbursement through the Employment Fund.
Note: This is lodged in ESS Web using the category ‘Medical Expenses’, see Employment Fund General Account Guidelines for further information.
Limitations of EF reimbursement
Each Provider can self-approve amounts (GST exclusive) to an overall cumulative total of $1000 per year. Once the total amount exceeds $1000 all subsequent claims must be approved by the department through the Account/Contract Manager.
If further claims are received after the cumulative total of $1000 is exceeded Providers will need to advise their Account Manager of additional claims immediately and will need to provide the following information, at a minimum:
• a copy of the Incident Report
• participant details
• activity details
• activity participation details
• copies of any medical reports and invoices.
The Account/Contract manager will advise the Provider in writing if approval is granted. The Provider must then reimburse the participant the amount approved by the department, in accordance with instructions provided by the department. The Provider is then able to claim a reimbursement of the amount paid to the participant from the EF.
What are the major policy exclusions?
• war
• exposure to nuclear radiation
• suicide or intentional self-injury or any such attempt
• flying or aerial activity except as a passenger in a properly licensed aircraft
• the insured persons’ criminal or illegal acts
• participating or training for any professional sport
• pregnancy, childbirth or miscarriage
• Note: this exclusion does not apply to an insured person who sustains an injury that necessitates medical treatment of a kind not given as part of a routine treatment for pregnancy or confinement.
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• sexually transmitted disease or A.I.D.S. or H.I.V. This exclusion does not apply to the Accidental H.I.V. Infection benefit.
• illness, except illness directly resulting from medical or surgical treatment rendered necessary by such injury
For additional Group Personal Accident Insurance information see the full insurance policy document available on the Provider Portal.
Combined (public and/or products) liability
What is covered?
This policy is provided by PEN Underwriting and covers participants’ liability arising out of their negligence that causes personal injury to third parties or damage to third parties’ property while participating in approved activities.
What are the major exclusions?
This insurance policy does not cover any liability arising from:
• any hovercraft, aircraft or any aerial device
• any watercraft that measures in excess of 10 metres in length
• any registered motor vehicles or vehicles required by law to be registered
• pollution, unless sudden and accidental
• asbestos
• product recall or defective work
• libel and slander related to advertising, broadcasting or telecasting activities
• fines, penalties, punitive or exemplary damages
• any activity undertaken that is not part of the approved activity.
For additional Combined Liability Insurance information see the full insurance policy document available on the Provider Portal.
What to do when a Third Party is injured or has their property damaged
The Provider and/or Host Organisation must:
1. Provide assistance to the injured person and notify any emergency services, if appropriate to do so.
2. Take all reasonable steps, following an accident or loss, to protect any person or property from any further injury, loss or damage.
3. Never admit liability verbally or in writing, or make any statement implying fault or accepting responsibility. To do otherwise may prejudice your claim with the Insurer. The Insurer has undertaken to accept the risks you have insured against, so it is their responsibility to accept or reject liability.
4. Immediately record all details (no matter how trivial it may seem at the time) of:
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(a) the incident (location/time)
(b) any third party who has, or may have, sustained injury, loss or damage
(c) any witnesses to the accident or loss.
5. Complete the Public and Products Liability Claim Form /Incident Report with the participant and forward it and any relevant documentation to [email protected].
6. If contacted by a third party, the third party’s doctor, or hospital requesting information as to the payment of the claim, please advise that any queries should be directed to Gallagher at [email protected] and forward any correspondence received from third parties to Gallagher and the department at [email protected].
Host combined (public and/or products) liability The department also purchases insurance coverage for hosts, owners of private property, land lease holders and farms who are receiving assistance from participants of Work for the Dole - Community Support Projects and other similar activities as advised by the department.
This insurance covers hosts and owners of private property, land lease holders and farms where their own public liability insurance does not provide for circumstances involving participants/volunteers on Commonwealth Government approved activities in jobactive.
If a Host Organisation receiving assistance from participants of Work for the Dole - Community Support Projects requires assistance in relation to this insurance, they should contact Gallagher directly.
For additional Combined Liability insurance information and policy exclusions refer to the full insurance policy document available on the Provider Portal.