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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.

Reasons for cliam rejection table

For more information

Email

Email Data and Evaluation Services on oirdata@oir.qld.gov.au