Claim status and reason for status
This data management bulletin assists insurers with the coding relationship of the claim status and reason for status fields.
The requirement to report the claim status and reason for status is specified within the Workers' compensation insurers' interface data specifications (PDF, 1.7 MB) for the monthly insurer interface as per 4.5.7 – Claim status and 4.5.11 – Reason for status.
Coding relationship
The reason for status must be supplied for claims where the claim status is either 'rejected', 'ceased' or 'suspended':
- Rejected (REJ) – the application for compensation is rejected
- Ceased (CSD) – the insurer has terminated entitlements to compensation
- Suspended (SPD) – entitlements to compensation are suspended.
The claims management processing to a claim status of rejected, ceased or suspended is attributed to a particular section of the Act. To measure and monitor the purpose of this claim status, a reason for status is required. The reason for status provides a separate code for each type of reason for rejecting, ceasing or suspending a claim under the Act. Insurers reject claims where, for some reason, the event or the person is not covered under the Act.
Claim status – rejected
Below is the list of applicable reason for status codes where the claim status is 'rejected'.
Code
| Rejection reason (REJ) | |
|---|---|
| Not a worker s.11 | 01 |
| Not an injury s.32(1—4) | 02 |
| Not an injury – psychiatric – excluded by s32(5) | 03 |
| Subjecting to abnormal risk during absence s34(1)(c) | 04 |
| Not a journey s.35 | 05 |
| Journey – traffic offence or breach of Criminal Code s36(2)(a) | 06 |
| Journey – substantial delay, interruption or deviation s.36(20(b) | 07 |
| Insurer not liable s.87 | 08 |
| Outside Queensland s.113 | 09 |
| Industrial deafness – excluded under s.125 – initial application | 10 |
| Industrial deafness – excluded under s.126 – further application | 11 |
| Out of time – excluded under s.131 | 12 |
| Invalid application s.132 | 13 |
| Fraud – excluded under s.537 | 14 |
| Persons other than workers – not covered under Div 3 Part 4 Ch 1 | 15 |
| Compensated under corresponding law s.116 | 16 |
| Self-inflicted injury – excluded under s.129 | 17 |
| Wilful misconduct – excluded under s.130 | 18 |
| Seafarer – excluded under s.121 | 19 |
| Miner – excluded under s.123 | 20 |
| False or misleading disclosure of pre-existing condition – s.571 | 21 |
Claim status – ceased
Insurers cease claims where, for some reason, the event or the person is no longer entitled to compensation under the Act. Below is the list of applicable reason for status codes where the claim status is 'ceased'.
Code
| Cessation reason (CSD) | |
|---|---|
| Entitlement to compensation stops if compensation under corresponding laws – s.116 | 41 |
| Entitlement to compensation ends if damages claim is finalised (settlement or judgement) – s.119 | 42 |
| Maximum statutory entitlement reached – s.140 | 43 |
| 5 year limit reached | 44 |
| Injury not likely to improve with further treatment – s.144B | 45 |
| Insurer review of entitlement to compensation | 46 |
| Worker receives notice of assessment – s.190 | 47 |
| Redemptions – s.171, s.172, s.173, s.176 | 48 |
| False or misleading disclosure of pre-existing condition – s.571 | 49 |
| Worker entitled only for interim period | 50 |
Claim status – suspended
Insurers suspend claims where, for some reason, the worker or person does not comply with sections of the Act. Below is the list of applicable reason for status codes where the claim status is 'suspended'.
Code
| Suspension reason | |
|---|---|
| Worker refused to be examined by a registered person – s.135 | 61 |
| Worker serving term of imprisonment – s.137 | 62 |
| Compensation not payable during suspension under Chapters 3, 4, 11 or 13 – s.138 | 63 |
| Insurer review of entitlement to compensation | 64 |
| Worker refuses to participate in rehabilitation – s.232 | 65 |
| The worker's absence from Australia will have an adverse effect - s.232ZH | 66 |
Reporting requirement
The reason for status must be supplied if the claim status is rejected, ceased or suspended. If the claim status is:
- rejected, the reason for status must be a valid code between 01 and 21
- ceased, the reason for status must be a valid code between 41 and 50
- suspended, the reason for status must be a valid code between 61 and 66.
Reason for status in reporting
The reason for status is used in insurer reporting as well as the Statistics report. Below is an excerpt from the Workers' Compensation Regulator's Statistics report.
For more information
Email Data and Evaluation Services on oirdata@oir.qld.gov.au