904

NEW ZEALAND GAZETTE

No. 41

14. Processing of Claims

14.1 Each Accredited Employer is to agree to use its best endeavours to ensure that employees suffering a work-related personal injury lodge any resulting claim with that Employer.

14.2 If any such claim is first lodged with the Manager, the Manager must promptly forward such claim to the Accredited Employer and, at the same time, notify the affected employee and known treatment provider that this has been done and that further contact should be direct with the Accredited Employer.

14.3 The Accredited Employer must agree that, for the purposes of sections 50 to 53 of the Act:

(a) It is the “receiving insurer” if an employee or ex-employee of that Accredited Employer lodges a claim with it under section 55; and

(b) It is the “managing insurer” if it is liable, under the Accreditation Agreement, to provide statutory entitlements to the employee who has suffered a work-related personal injury.

This is unless the Act or the Framework or the context requires otherwise.

14.4 For the avoidance of doubt, an Accredited Employer must agree that, if it receives a claim for which, under the Accreditation Agreement, it is not responsible it must forward such claim on to the insurer who is responsible and, in the case of doubt, to the Manager.

14.5 Notwithstanding paragraphs 13.2, 14.1, 14.2 and 14.3, if the Manager receives a claim for a work-related personal injury direct from an employee of an Accredited Employer in circumstances where the Manager, in its absolute discretion, considers that, for reasons of a sensitive, personal nature related to the affected employee and/or related to the circumstances giving rise to the claim, it is inappropriate for the Accredited Employer to self manage the claim, the Manager may elect to retain the management of the claim for such period as it thinks fit.

14.6 If, under paragraph 14.5, the Manager has elected to retain management of the claim, the Manager must keep the Accredited Employer informed to the greatest extent practical consistent with the interests of the employee and the reasons giving rise to it managing the claim in the first place.

14.7 The Accredited Employer must agree that if, under paragraph 14.5, the Manager has elected to retain management of the claim, the Accredited Employer will reimburse the Manager all costs and expenses incurred by the Manager in relation to the claim (including proper allowance for the case management expenses that would not have been incurred by the Manager but for the decision to handle the claim).

14.8 Nothing in paragraphs 14.5, 14.6 and 14.7 are to be read:

(a) As reducing the rights of an insured to elect, under section 32(7) of the Act, to have a personal injury (of the type described in that section) regarded as a non-work injury; or

(b) As altering the consequences of such an election.

15. Employee Review Rights

15.1 The rights of employees of an Accredited Employer to dispute decisions by the employer as to statutory entitlements are those contained in Part 6 of the Act.

15.2 The Accredited Employer must agree that, for the purposes of a review under Part 6 of the Act:

(a) The Manager is to provide the reviewer under section 138(2) of the Act;

(b) The Accredited Employer is to be responsible for arguing the insurer’s interest in the review;

(c) The Accredited Employer is liable to pay the Manager the reasonable cost of conducting the review; and

(d) For all other purposes, when the Manager is referred to in Part 6 (the term “Manager” there being included within the term “insurer”), then, if the context permits, the Accredited Employer is to stand in the position of the Manager and is liable for the resulting expense.

16. Employer Liability Cap

16.1 For the purposes of this paragraph 16 “Limit” means any liability, in respect of work-related personal injuries suffered by its employees in any one Cover Period, over 200% of the “Risk” as defined in paragraph 16.4.

16.2 No Accredited Employer within the Full Self Cover Plan is to be liable for more than the Limit with the Manager being responsible for the excess.