Once the insurer has received the initial notification of injury, the insurer must:
- start provisional payments within seven calendar days unless there is a reasonable excuse or
- delay starting provisional weekly payments by issuing a reasonable excuse within seven days or
- determine liability.
Section 267 (2) of the 1998 Act defines what a reasonable excuse may be.
- If there is insufficient medical information i.e., defects in the certificate of capacity, a lack of clear diagnosis are the types of reasons an insurer can rely upon to say there is a reasonable excuse to delay making provisional weekly payments of compensation.
- If the insurer is unable to contact the worker after two attempts by telephone one attempt by writing.
- The worker refuses to allow the insurer to collect information to investigate the claim.
- If the insurer believes the worker is not a “worker” within the meaning of the legislation and/or is not work-related.
- The worker did not provide the notification of injury within two months of the incident.
A reasonable excuse may apply to the weekly payments but not to provisional medical expense payments.
Section 280 of the 1998 Act allows an insurer to accept provisional liability for payment of medical expenses however in doing so is not required to make a formal determination of liability of the claim. The insurer can accept provisional liability for medical expenses up to $10,000.
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