Workers' Compensation and Rehabilitation Amendment Regulations (No. 11) 1999 (WA)

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WESTERN	6145
AUSTRALIAN GOVERNMENT

PERTH, TUESDAY, 14 DECEMBER 1999 No. 234 SPECIAL

PUBLISHED BY AUTHORITY JOHN A. STRIJK, GOVERNMENT PRINTER AT 4.00 PM

WORKERS’ COMPENSATION AND

REHABILITATION ACT 1981

_________

WORKERS’

COMPENSATION AND
REHABILITATION
AMENDMENT
REGULATIONS (No. 11)

6146	GOVERNMENT GAZETTE, WA	[14 December 1999
14 December 1999]	GOVERNMENT GAZETTE, WA	6147

Workers’ Compensation and Rehabilitation Act 1981

Workers’ Compensation and
Rehabilitation Amendment Regulations

(No. 11) 1999

Made by the Governor in Executive Council.

1.             Citation

These regulations may be cited as the Workers’ Compensation and Rehabilitation Amendment Regulations (No. 11) 1999.

2.             The regulations amended

The amendments in these regulations are to the Workers’
Compensation and Rehabilitation Regulations 1982*.

[* Reprinted as at 14 February 1995.

For amendments to 7 December 1999 see 1998 Index to
Legislation of Western Australia, Table 4, p. 354, and Gazette
13 and 16 April, 22 June and 15 October 1999.]

3.             Regulation 19J amended

Regulation 19J(1) is repealed and the following subregulation is inserted instead —

“

(1) A referral under section 93D(5) of the Act —

(a)	is to be made in the form of Form 22 in Appendix I; and
(b)	is to nominate in the Form 22 one, and only one, relevant level of disability in respect of which the referral is made.

”.

4.             Regulation 19M replaced

Regulation 19M is repealed and the following regulation is inserted instead —

“

19M. Election to retain right to seek common law
damages

(1) An election under section 93E(3)(b) of the Act —

(a) is to be made in the form of Form 25 in Appendix I (the “election form”) and lodged with the Director; and

6148 GOVERNMENT GAZETTE, WA [14 December 1999

(b) cannot be made unless —

(i)      it is agreed that the degree of disability is not less than 16%; or

(ii)      it is determined that the degree of disability is not less than 16%.

(2)	If it is agreed that the degree of disability is not less than 16% the election form is to be accompanied by Form 24 in Appendix I unless an agreement as to the degree of disability for the purposes of
section 93E(3)(a), (4) or (9) of the Act was recorded under regulation 19K before the lodgment of the election form.
(3)	If it is determined that the degree of disability is not less than 16% the election form is to be accompanied by evidence of the determination unless a determination of a dispute as to the degree of disability was recorded under regulation 19L before the lodgment of the election form.
(4)	Subject to subregulation (5), on the day on which the Director receives the election form the Director is to —

(a) record —

(i)	under regulation 19K(2)(a) the agreement (if any) accompanying the election form; or
(ii)	under regulation 19L(2)(a) the determination (if any) accompanying the election form;

(b)	register the election in a register kept for that purpose; and
(c)	complete the relevant section of the election form and give a copy of it to the worker and the employer.

(5)	The Director may decline to register an election if the Director is satisfied that the worker does not fully understand the consequences of the registration of the election.
(6)	This regulation applies to an election under section 93E(3)(b) of the Act that is commenced on or after the day on which the Workers’ Compensation and Rehabilitation Amendment Regulations (No. 11) 1999 come into operation.

”.

14 December 1999] GOVERNMENT GAZETTE, WA 6149

5.             Regulation 19N replaced

Regulation 19N is repealed and the following regulation is inserted instead —

“

19N. Extension of time to make election under
s. 93E(3)(b)

(1)	In this regulation —
“extension period” means the period of time that ends

6 months after the termination day;

“termination day” has the meaning that it has in

section 93E of the Act.

(2) For the purposes of section 93E(7) of the Act, the
circumstances in which the Director may extend the
period of time within which an election can be made
under section 93E(3)(b) of the Act are if the Director is
satisfied that —

(a)	the worker will require major surgery in respect of the disability in the extension period;
(b)	medical evidence that the worker will require major surgery in respect of the disability in the extension period has not been obtained from a medical practitioner who is a specialist in a relevant field of medicine despite all reasonably practicable steps having been taken by or on behalf of the worker to obtain that evidence; or
(c)	a medical panel under section 36 of the Act has determined that the worker’s disability is of a kind mentioned in section 33 or 34 of the Act.

(3) An application for an extension of time under
subregulation (2)(a) is to be —

(a)	made in the form of Form 26 in Appendix I;
(b)	accompanied by medical evidence from a medical practitioner who is a specialist in a relevant field of medicine; and
(c)	lodged with the Director at least 21 days before the termination day.

(4) An application for an extension of time under
subregulation (2)(b) is to be —

(a)	made in the form of Form 27 in Appendix I;
(b)	accompanied by such evidence, in addition to that provided in the Form 27, as may be requested by the Director about —

(i) the requirement for the worker to have

subregulation (2)(b); or

6150 GOVERNMENT GAZETTE, WA [14 December 1999

(ii)      the action taken by or on behalf of the worker to obtain the medical evidence mentioned in subregulation (2)(b);

and

(c) lodged with the Director at least 21 days before the termination day.

(5) An application for an extension of time under
subregulation (2)(c) is to be —

(a)	made in the form of Form 26 in Appendix I;
(b)	accompanied by evidence of the medical panel’s determination; and
(c)	lodged with the Director at least 21 days before the termination day.

(6) Within 14 days of receiving the application the
Director is to —

(a)	decide whether to extend the period within which the election can be made;
(b)	set the extension period in accordance with section 93E(7); and
(b)	complete the relevant section of the application form and give a copy of it to the worker and the employer.

(7) This regulation applies to an application for an
extension under section 93E(7) of the Act of the period
within which an election may be made that is lodged
with the Director on or after the day on which the
Workers’ Compensation and Rehabilitation
Amendment Regulations (No. 11) 1999 come into
operation.

”.

6.             Regulation 19P inserted

After regulation 19O the following regulation is inserted in
Part 3A —

“

19P. Notification to workers about elections as to
common law damages

(1) The employer of a worker who has an unfinalized
claim for compensation under the Act is to give the
worker written notice of —

(a)	the requirement under section 93E(3)(b) of the Act for the worker to elect to retain the right to seek damages; and
(b)	the date by which the election is to be made.

14 December 1999] GOVERNMENT GAZETTE, WA 6151

(2) The employer is to give the notice mentioned in
subregulation (1) —

(a)	if a dispute resolution body orders that weekly payments of compensation are to commence, within 7 days of the day of the order; or
(b)	in any other case, 3 and 5 months from the day on which weekly payments commenced.

”.

7.             Appendix I amended

(1) Forms 3A and 4 in Appendix I are deleted and the following
forms are inserted instead —

“

Form 3A

[r. 6B]

Workers’ Compensation and Rehabilitation Act 1981

[section 57A(3)(a)]

Insurer’s Notice that Liability is Accepted

To:

1. ............................................................................................................................

[name and address of worker to whom the claim relates]

.................................................................................................................................

2. .............................................................................................................................

[name and address of employer]

.................................................................................................................................

From: ......................................................................................................................

[name and address of insurer]

.................................................................................................................................
* Claim number:...................................
Date of accident: ..................................
Nature of incapacity: ..............................................................................................
.................................................................................................................................
Date claim made by employer: ............................................
In respect of the above claim you are notified that liability is accepted in respect
of the weekly payments claimed by the worker.
Date on which weekly payments are proposed to commence:…………………...

[Insurer to liaise with employer to ascertain the commencement date]

Signed on behalf of the insurer: ......................................................................…...

Date: ....................................................

* Please provide this claim number to your general practitioner at your next
appointment in relation to this claim

6152 GOVERNMENT GAZETTE, WA [14 December 1999

Form 4

Workers’ Compensation and Rehabilitation Act 1981

[section 61(1)]

Final Medical Certificate

Claim No.

(if known)

To (name and address of worker’s employer)
.………………………........................................................................................................................

..........................................................………………………………...................................................

WORKER’S DETAILS

First name(s): …………………………………………. Surname: ………………………………… Address: …………………………………………………………………………………………….. Telephone: ………………………………………………………………………………………….. Date and place of occurrence of disability: …. / …. / ……. ……………………………………….

MEDICAL ASSESSMENT

Having examined the worker, it is my opinion that as from ….. / …… / ………….
r the worker has total capacity for work.
r the worker has partial capacity for work.

r the worker’s incapacity is no longer a result of the disability.

It is also my opinion that as from ….. / …… / …………. the worker is
r fit.
r fit for alternative duties with the following limitations:
...............…….........……………………….........................................................................................
.....................……………………………............................................................................................
...............................................................……………………………..................................................

.........................................................................................................……………………………........

Grounds for the opinion in medical assessment
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.......…………………………………………………………………………………………………..

14 December 1999] GOVERNMENT GAZETTE, WA 6153

(2) Forms 22, 23, 24, 25, 26 and 27 in Appendix I are deleted and
the following forms are inserted instead —

“

Form 22

Workers’ Compensation and Rehabilitation Act 1981

Referral of Question of Degree of Disability

[r. 19J(1)]

Worker’s details

Surname Other names

Date of birth	Sex	Occupation
Address

Postcode

Telephone no.

Employer’s details

Name

Address

Postcode

Telephone no.	WorkCover no. (if known)
Contact person
Title	Telephone no.
Insurer’s details
Name
Address

Postcode

Date weekly payments commenced (if	Claim no. (if known)
applicable).
Contact person
Telephone no.

6154 GOVERNMENT GAZETTE, WA [14 December 1999

Disability details

Description of disability

Date disability occurred

Date weekly payments commenced

Degree of disability as assessed

Relevant level of disability (see s. 93E(3) of the Act)

by medical practitioner

Nominate only one relevant level of disability.

❏	not less than 30%
❏	not less than 16%

Tick if the worker and the employer cannot agree on whether the degree of

disability is not less than the relevant level	❏
The action taken by or on behalf of the worker to obtain the employer’s agreement

Signature	Date
of worker	/ /
Lodging this form
This form should be lodged with —

Director, Conciliation and Review Directorate
WorkCover WA

Perth, Western Australia

You must also give to the Director medical evidence from a medical practitioner indicating that,

in his or her opinion, your degree of disability is not less than the relevant level.

Form 23

Workers’ Compensation and Rehabilitation Act 1981

Notice of Referral of Question of Degree of Disability

[r. 19J(2), (3)]

Worker’s details

Surname	Other names
Address

Postcode

Telephone no. Occupation

14 December 1999] GOVERNMENT GAZETTE, WA 6155

Employer’s details

Name

Address

Postcode

Telephone no.

WorkCover no. (if known)

Disability details

Description of disability

Date disability occurred

Degree of disability as assessed

Relevant level of disability

by medical practitioner

❏	not less than 30%
❏	not less than 16%

Question referred

The question of whether the worker’s degree of disability is or is not less than the relevant level has been referred to the Director, Conciliation and Review Directorate, for consideration.

Medical evidence

Accompanying this notice is a copy of the medical evidence provided by the worker which indicates that in the opinion of the worker’s medical practitioner the worker’s degree of disability is not less than the relevant level.

Objection

If you (the employer) consider the worker’s degree of disability is less than the relevant level, you should complete the bottom section of this form and return it to the Director within 21 days of receiving this notice.

If you do not notify the Director within 21 days you will be taken to have agreed that the

worker’s degree of disability is not less than the relevant level

Signature

of Director	Date	/ /
Employer’s objection
Employer’s assessment of degree of disability
Signature of employer	Date	/ /

6156 GOVERNMENT GAZETTE, WA [14 December 1999

Form 24

Workers’ Compensation and Rehabilitation Act 1981

Degree of Disability Agreement

[r. 19K(1), (2)]

Worker’s details

Surname	Other names
Address

Postcode

Telephone no.	Occupation
Employer’s details
Name
Address

Postcode

Telephone no.	WorkCover no. (if known)
Insurer’s details
Name
Address

Postcode

Date weekly payments commenced (if	Claim no. (if known)
applicable).
Contact person
Telephone no.
Disability details
Description of Disability
Date disability occurred

14 December 1999] GOVERNMENT GAZETTE, WA 6157

Agreement

Agreed degree of disability Agreed degree of disability is —

(insert actual figure e.g. 22%)	%	❏	not less than 30%
❏	not less than 16%

Signature of Worker	Date	/ /
Signature of	Name of
witness	witness
Signature of Employer	Date	/ /
Signature of	Name of
witness	witness
Recording of agreement

Date of recording Record no.

Signature of
Director Date / /

Form 25

Workers’ Compensation and Rehabilitation Act 1981

Election to Retain Right to Seek Damages

[r. 19M(1)]

Worker’s details

Surname Other names

Date of birth	Sex	Occupation
Address

Postcode

Telephone no.

6158 GOVERNMENT GAZETTE, WA [14 December 1999

Employer’s details

Name

Address

Postcode

Telephone no.	WorkCover no. (if known)
Contact person
Title	Telephone no.
Insurer’s details
Name
Address

Postcode

Date weekly payments commenced	Claim no. (if known)
Contact person
Telephone no.
Disability details
Description of disability
Date disability occurred
Has a Degree of Disability Agreement (Form 24) already been recorded	Yes ❏
by the Director?	No ❏
If yes:	…………………..date when recorded
…………………..record number

Degree of disability as agreed…………………….%

Has the determination of a dispute as to the degree of disability already	Yes ❏
been recorded under reg. 19L by the Director?	No ❏
If yes:	…………………..date when recorded
…………………..record number

Degree of disability as determined……………….%

14 December 1999] GOVERNMENT GAZETTE, WA 6159

Signature of Worker Date / /

Warning

The registration of this election will, in most cases, prevent you from
continuing to receive statutory benefits under the Workers’
Compensation and Rehabilitation Act 1981.

You should seek appropriate independent advice before lodging this form.

Registration of election

Date of registration Registration no.

Signature
of Director Date / /

Form 26

Workers’ Compensation and Rehabilitation Act 1981

Application for Extension of Time to Make Election (medical
evidence available)

[r. 19N(3)(a) and (5)(a)]

Worker’s details

Surname Other names

Date of birth	Sex	Occupation
Address

Postcode

Telephone no.

Employer’s details

Name

Address

Postcode

Telephone no. WorkCover no. (if known)

6160 GOVERNMENT GAZETTE, WA [14 December 1999

Contact person

Title	Telephone no.
Insurer’s details
Name
Address

Postcode

Date weekly payments commenced	Claim no. (if known)
Contact person
Telephone no.
Disability details
Description of disability

Degree of disability

Date disability occurred (as assessed by worker’s medical specialist)

%

Extension of time sought

The application for extension of time is made under —

❏ regulation 19N(2)(a) OR ❏ regulation 19N(2)(c)

Extension sought until

Signature of Worker	Date	/ /
Lodging this form
This form should be lodged with —

Director, Conciliation and Review Directorate
WorkCover WA

Perth, Western Australia

If applying under regulation 19N(2)(a) you must also give to the Director medical evidence from determination.

a medical practitioner who is a specialist in a relevant field of medicine indicating that you will
require major surgery in the extension period (see regulation 19N(1)).

14 December 1999] GOVERNMENT GAZETTE, WA 6161

Granting of extension

An extension of time to make an election under section 93E(3)(b) of the Act —

❏ is granted until / / OR ❏ is not granted

The extension of time is granted under —

❏ regulation 19N(2)(a) OR ❏ regulation 19N(2)(c)

Signature
of Director Date / /

Form 27

Workers’ Compensation and Rehabilitation Act 1981

Application for Extension of Time to Make Election (medical evidence not
yet available)

[r. 19N(4)(a)]

Worker’s details

Surname Other names

Date of birth	Sex	Occupation
Address

Postcode

Telephone no.

Employer’s details

Name

Address

Postcode

Telephone no.	WorkCover no. (if known)
Contact person
Title	Telephone no.
Insurer’s details
Name

6162 GOVERNMENT GAZETTE, WA [14 December 1999

Address

Postcode

Date weekly payments commenced	Claim no. (if known)
Contact person
Telephone no.
Disability details
Description of disability
Date disability occurred
Extension of time sought
Extension sought until

State grounds on which the worker submits that he or she will require major surgery in respect of the disability in the extension period (see regulation 19N(1))

State the action that has been taken by or on behalf of the worker to obtain medical evidence from a medical practitioner who is a specialist in a relevant field of medicine that the worker will require major surgery in respect of the disability in the extension period

(attach separate sheet if insufficient room)

Signature of Worker	Date	/ /
Lodging this form
This form should be lodged with —

Director, Conciliation and Review Directorate
WorkCover WA

Perth, Western Australia

You must also give to the Director any further evidence that the Director may request in relation

to this application.

14 December 1999] GOVERNMENT GAZETTE, WA 6163

Granting of extension

An extension of time to make an election under section 93E(3)(b) of the Act —

❏ is granted until / / OR ❏ is not granted

Signature	Date
of Director	/ /

”.

By Command of the Governor,

M. C. WAUCHOPE, Clerk of the Executive Council.

6164 GOVERNMENT GAZETTE, WA [14 December 1999

MEDICAL PRACTITIONER’S DETAILS

Name: ………………………………………… Registration No.: ..……………………………….. Address: …...………………………………………………………………………………………... Telephone: …………………………………….

Fax: ……………………………………………

Signature: ……………………………………. Time & Date of examination: ..……………………

For workers’ compensation information or assistance contact

WorkCover WA’s Infoline: 08 9388 5555 Country callers: 1 800 670 055

”.