In most cases, standard settlement terms allow a period of 28 days for payment of settlement monies to a claimant following receipt of statutory “clearances” from Medicare and Centrelink. A compensation payer has statutory obligations to notify Centrelink and Medicare following resolution of a claim and to attend to statutory paybacks prior to releasing settlement/judgment monies.
Part 3.14 of the Social Security Act 1991 (Cth) imposes an obligation on a “compensation payer” to reimburse the Commonwealth any “compensation affected payments” received by a “compensation recipient” during the “lump sum preclusion period”. This means that a person who is responsible for the payment of compensation to a claimant must reimburse the Commonwealth any compensation affected payments received by a claimant during the relevant preclusion period. The preclusion period is calculated by reference to Section 117O of the Social Security Act. The preclusion period varies in each individual matter as a formula is applied based on the settlement/judgment amount and whether a claimant has received periodic compensation payments, a lump sum compensation payment or both.
Compensation affected payments include a range of social security benefits including unemployment benefits, various disability pensions and other payments and allowances. A full list of relevant payments may be found in Section 17 of the Social Security Act.
Liability to reimburse Centrelink generally arises following settlement/judgment if a claim for economic loss has been made. A compensation payer must notify Centrelink of the settlement/judgment amount. Centrelink then applies the statutory formula and provides written notice to a compensation payer confirming the recoverable amount. Upon receipt of a recovery notice, the compensation payer becomes liable to repay the amount specified in the notice. It is a strict liability offence for an insurer to make a payment to a claimant before any monies owing to the Commonwealth have been reimbursed. The insurer’s liability to the Commonwealth is discharged upon payment of the amount specified in a recovery notice.
Liability to reimburse Centrelink usually only arises in circumstances where a claim for economic loss has been pursued by a claimant. For claims that resolve without a component for economic loss, a request for a clearance usually results in a clearance being issued confirming that no payback to Centrelink is required. Insurers usually request a clearance even in such circumstances so as to ensure that they have discharged any liability to the Commonwealth.
In order to avoid unnecessary delays in receiving settlement/judgment monies at the conclusion of a claim, it is important to notify Centrelink and request a clearance as soon as possible.
Lawyers who act for claimants must ensure the prompt execution and return of all necessary documentation so as to avoid unnecessary delays. Lawyers must also ensure that all documents are completed properly otherwise they are likely to be rejected by Centrelink resulting in delays and financial hardship to claimants who have had their Centrelink benefits suspended following settlement/judgment.
In circumstances where a claimant is suffering financial hardship or has other extenuating circumstances, it is recommended that lawyers contact Centrelink directly to request that a clearance be given priority. This information should also be conveyed to the insurer or the insurer’s legal representatives at the time of settlement so as to avoid unnecessary delays.
The Medicare payback scheme is governed by the Health and Other Services (Compensation) Act 1995.
In circumstances where a claimant has received Medicare benefits arising from medical expenses in respect of the compensable injuries for which compensation has been claimed, the total value of the benefits must be reimbursed to the Commonwealth if the claim resolves for a sum in excess of $5,000.00.
The “notifiable person” (usually the insurer or compensation payer) must notify Medicare in writing within 28 days of the date of judgment or settlement. Notification may be made by completing a Section 23 Notice titled “Medicare Compensation Recovery Notice of Judgment or Settlement”.
It is important that lawyers acting on behalf of claimants promptly request a Medicare History Statement following lodgement of a claim so that all Medicare benefits previously received in respect of a claimant’s compensable injuries may be identified and a Notice of Charge issued. A Notice of Charge is only valid for a period of 6 months and it is therefore important for lawyers to regularly update these notices to ensure that a valid Notice of Charge is available at the time of settlement.
A claimant is required to complete the Medicare History Statement to the best of his or her recollection and does not need to cross reference each individual benefit with records obtained from treatment providers. Medicare will contact a claimant if an issue arises or if there appears to be an error. It is extremely important that a claimant completes the Medicare History Statement promptly and returns the completed documents to Medicare. If the documents are not returned to Medicare within the prescribed timeframe of 28 days, Medicare will deem all listed benefits as being related to the claim and will issue a “deemed” Notice of Past Benefits for the full amount whether or not such benefits were in fact related to the subject claim.
To avoid unnecessary delays in claimants being paid the full amount of their settlement/judgment monies, lawyers acting on behalf of claimants should attempt to ensure that there is always a valid Notice of Charge retained on file so as to avoid the need for advance payments. A copy of a valid notice should also be provided to the insurer at the time of settlement so as to avoid an advance payment inadvertently being made.
If there is a valid Notice of Charge at the time of settlement, this amount can usually be included as part of a claimant’s claim for out of pocket expenses. A compensation payer is then only required to attend to payment of the amount specified in the Notice of Charge to discharge their liability to Medicare following settlement/judgment.
If there is no valid Notice of Charge at the time of settlement/judgment, an “advance payment” representing 10% of the total settlement/judgment sum may be made. In the event of an advance payment being utilised, notice must be provided to a claimant pursuant to Section 33A of the Act of the intention to make an advance payment. Any advance payment must also be made within 28 days of the judgment/settlement. Medicare then have a period of 3 months to conduct a reconciliation and issue a refund once the payback figure has been determined.
Claimants can avoid the need for a 10% advance payment being made in circumstances where there is an expired Notice of Charge but no additional injury related benefits have been paid since the last Notice of Past Benefits was issued. In such circumstances, a claimant may complete a Section 23A Statement and return it to the compensation payer with the other settlement documentation. The insurer will then only be required to pay the amount specified in the expired Notice of Past Benefits.
It is an offence for a compensation payer to pay the claimant any part of the compensation amount unless the required payment has been made to Medicare or the specified amount has been withheld from the claimant. In the event that settlement monies are disbursed prior to reimbursement to Medicare being made, a compensation payer is liable to make the payment over and above the settlement funds. Criminal sanctions also apply as a result of failure to comply with such obligations.