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WORKERS' COMPENSATION AND REHABILITATION REGULATION 2014 - REG 117X
Deciding payment request
117X Deciding payment request
(1) For section 232R (2) of the Act , this section prescribes matters about an
insurer deciding a payment request for an expense for the treatment, care or
support of an eligible worker.
(2) If the insurer makes an
information request and the person of whom it is made does not provide the
information requested by the stated day or a later day agreed between the
insurer and the person— (a) the payment request lapses; and
(b) the insurer
is not required to approve or refuse the request.
(3) The insurer must
approve the payment request if— (a) the expense is incurred in the
eligibility period for the worker; and
(b) the treatment, care or support the
request relates to is an approved service for the worker.
(4) To remove any
doubt, it is declared that the insurer may approve the payment request even
though the treatment, care or support the request relates to is not an
approved service for the worker.
(5) In this section—
"approved service" does not include treatment, care or support that is
excluded treatment, care or support, unless— (a) if a support plan has been
made for the eligible worker—the excluded treatment, care or support is
specifically stated in the support plan to be— (i) treatment, care or
support for, or relating to, the worker’s treatment, care and support needs
resulting from the worker’s serious personal injury the insurer considers is
necessary and reasonable in the circumstances; or
(ii) treatment, care or
support resulting from another injury resulting from the same event as the
worker’s serious personal injury the insurer considers is necessary and
reasonable in the circumstances; or
(iii) treatment, care or support the
insurer agrees to, wholly or partly, pay for under chapter 4A of the Act ; or
(b) if a support plan has not been made for the eligible worker—the excluded
treatment, care or support is specifically approved under an approval of a
service request relating to the worker.
"information request" , for a payment request, means a written request made by
the insurer— (a) asking a relevant person for further information about the
payment request by a stated day of at least 10 business days after the insurer
makes the request; and
(b) stating that, if the requested information is not
given to the insurer by the stated day, the payment request will lapse.
"relevant person" , for an information request, means— (a) the person who
made the payment request; or
(b) if the person who made the payment request
is not the eligible worker—the eligible worker.
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