Requirements for Stage 2 Extension of Funding

Purpose

This Practice Note provides guidance on the practice and implementation of clause 3.2.3 of the ILARS Funding Guidelines (Guidelines) as they apply to an extension of funding to Stage 2.

This Practice Note includes:

• The operational rules and criteria for IRO to approve Stage 2 funding
• The information required to support a request for Stage 2 funding
• The procedure to be followed when requesting Stage 2 funding

Criteria, Practice and Procedure

Criteria

IRO will fund Stage 2 applications to investigate and pursue where possible (clause 3.2.1):

• A claim for benefits
• A dispute about a decision, claim or any aspect of a claim
• The assertion of a threshold (except threshold for a work injury damages claim)

Including all work up to the commencement of proceedings in the Commission (including attempting resolution of the claim or dispute).

The requirement for approval of an extension of funding for Stage 2 is for the request to be assessed as ‘having some merit’ means that there is a basis in fact and law to conclude that the worker has a claim or dispute to pursue which may result in a successful outcome” (part 3.2.3).

Practice

The Lawyer should provide an explanation or short reasons together with any evidence or material available which supports the request for funding or extension of funding and demonstrates that the purpose for which the extension is sought has some merit (clause 3.2.3).

Clause 3.2.3 provides some examples of the evidence or material which may be required. providing this type of evidence or material will not necessarily be sufficient to demonstrate there is ‘some merit’ to the claim or dispute.

Procedure

When requesting an extension of funding, Approved Lawyers are required to provide:

• an explanation, or short reasons to support the application
• sufficient information to support the application, for example:
       - copy of the insurer’s notice
       - medical information or statement from the worker which supports the application
       - weekly payment information 
• information substantiating what the claim is for, for example a claim for weekly benefits, permanent impairment, medical dispute
• specify if there has been a declinature of liability and the issues with the notice

Please note: 

• For all requests for an extension of stage 2 funding, please submit your request as a new email (i.e. not replying to previous emails) to the ILARS Mail Inbox (ILARSALmail@iro.nsw.gov.au) with the subject “Stage 2 Extension of Funding”. This will assist with your request being allocated to the triage team for prompt assessment and reallocation. Failure to address the subject line in this manner will cause delay in assessment of your request.
• For all disbursement only funding requests please do not use ‘extension’ within the request for correct allocation of your funding request

Examples

Medical expenses

Indicate that the funding relates to surgery, medical treatment, or domestic assistance.

Provide an explanation or short reasons in support and relevant documents including:

• Whether the surgery, treatment or domestic assistance has been recommended to the injured worker
• Whether a treatment request has been sent from the provider to the insurer seeking approval. Stage 2 funding is not to deal with claims management issues (ie sending a copy of a treatment request from a provider to the insurer) 
• Where there is an insurer decision which is disputed by the injured worker, provide a copy of the relevant section 78 notice
• Where the matter relates to a claim for surgery, provide a copy of the treating specialist’s request for approval to the insurer and the relevant report from the treating specialist
• Where the matter relates to claim for medical treatment, provide relevant supporting treating doctor recommendation for treatment
• Where the matter relates to a claim for domestic assistance, provide the relevant supporting doctor recommendation for assistance

Weekly payments
To investigate a claim for weekly payments, specify whether funding is being sought with respect to disputed wages and/or a PIAWE dispute. 

  PIAWE

• For a PIAWE dispute, provide the basis for argument that the insurer’s calculation is incorrect 
• Provide supporting documents, such as payslips which address the correct PIAWE

  Weekly payments

• For a weekly payments dispute, provide a copy of declinature notice
• Provide the basis for the argument that the insurer’s decision is incorrect

Lump sum compensation

• State that funding is being sought to investigate a section 66 claim
• Provide support to demonstrate that there is an impairment for example, medical reports, radiological scans, injured worker statement and/or clinical records
• Specify which body parts are to be investigated
• Specify what treatment/surgeries the worker has undergone which are relevant to the assessment of whole person impairment
• Approved Lawyers should state why they believe the injured worker is likely to have reached maximum medical improvement (“MMI”) when seeking an extension of funding. MMI is considered to occur when the worker’s condition is well stabilised and is unlikely to change substantially in the next year with or without medical treatment.

Physical

• Medical or other evidence to establish the injured worker meets the criteria under AMA5 and the Evaluation of Permanent Impairment Guides

Examples of evidence of pathology or studies:

•  Gastroenterological – evidence of pathology
• Sleep apnoea – evidence of sleep study

Psychological

• Provide information/evidence relevant to the PIRS assessment which includes medical information and/or statement from the injured worker

Commutations
Documents must be provided to indicate insurer open to commutation

Work Capacity Decisions

• Provide a copy of the work capacity decision
• Provide the basis for the argument that the work capacity decision is incorrect
• Provide supporting medical information to support your submissions

Requirements for Stage 2 Extension of Funding (PDF)