Claim Estimates and WorkSafe Premiums

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1 Claim Estimates and WorkSafe Premiums Introduction For employers with annual rateable remuneration of over $200,000 premiums for WorkSafe insurance are calculated taking into account their claims performance relative to their industry peers. This calculation methodology is referred to as the experience rated calculation. Employers with annual rateable remuneration of less than $200,000 have their premium calculated using the experience of their industry, this is referred to as the industry rated calculation. To fairly measure an employer s relative claims performance their size, based on their rateable remuneration is taken into account in the experience rated calculation. To provide equity to the cost of the claims used in determining an employer s performance a predicted total claim cost is used for each claim. Determining total claim costs The total claims cost used by WorkSafe in the employer performance calculation has two broad monetary components. The first component is the actual claims costs. These are the cumulative costs incurred by the claim to that point in time. The second component is the estimated future cost of the claim. These costs are determined using a statistical estimating model and reflect the potential costs that the claim may incur over the future. By having the claim cost expressed as a total of the actual and estimated future costs each claim is given a fair weighting in the determination of employer performance. Claims are used three times (for three consecutive financial years) in the employer performance calculation. If only the actual costs of claims were used in the calculation then similar claims would have differing costs based on how old the claim was rather then their having relatively the same cost. Estimates Every claim that is made against a Victorian employer has an estimate. Estimates reflect the costs that a claim may incur in the future, based on the likelihood that they will be incurred. Estimates will change from month to month based on what is known about the claim and what might have changed over the month since the previous estimate, for example the worker may have returned to work or their condition may have been re-diagnosed. While the estimated future claim cost is calculated every month it is only the estimate determined in July is used in the calculation of an employer s performance rate and effects the premium calculation. This is not to say that the other monthly estimates have no value, they provide the employer with the most up to date prediction of the future cost of the claim and an indication of the total cost that will be used in the next premium calculation. The Estimating Model Claim estimates are based on a statistical model that uses information from all the previous claims that have been made in the life of the Victorian scheme; some 25 years of claim information. A claim s estimate, when it is first developed, is based on the experience of claims with similar characteristics (the injury type, the bodily location of the injury, the age, gender and occupation of the injured worker, etc.) and over time it reflects more of the individual claim s experience and the anticipated treatment and rehabilitation process. Estimates provided by the statistical model can appear to employers to be higher than the amount they believe the claim will cost in the future. It is important to remember that the estimating model factors in future costs making allowances for the probability that the claim

2 will see different types of payment. It is also important for employers to remember that this is the case for all claims and the costs are being used to compare employer performance relative to that of their industry. Claims and the premium calculation Claims are used three times in the premium calculation, in consecutive financial years. The claims that are used in the premium calculation are taken from a period referred to as the claims reporting period. This period changes from financial year to financial year and is usually the three calendar years preceding the financial year. For example the claims reporting period for 2013/14 is the three calendar years ending 31 December 2012 (the three years commence on 1 January 2010). 2013/14 Claims Reporting Period 1/1/ /12/ / / / /13 Premium Year 2013/14 Every claim that is made against a Victorian employer s WorkSafe Insurance policy within the reporting period is used in the calculation. The status of the claim does not affect its use in the calculation; in other words claims that are open, closed, rejected or of any other status will still be used in the determination of an employer s claims performance. Claims that are received after the end of the reporting period and before the calculation of employer premiums are not used until the following year s premium calculation. They are not used in the premium calculation because all claims are given three months before an estimate of the future costs is first established and then a further three months to develop and stabilise so they are still within this 6 month period at the time of the premium calculation. These claims will be used in the subsequent three years premium calculations. There are circumstances where some or all of the costs of a claim are recovered from another party. This may be as the result of a WorkSafe prosecution of a negligent supplier or host employer or it may be as a result of motor vehicle involvement in the injury and the Transport Accident Commission providing compensation towards the cost of the claim. How claims are used in the premium calculation Only employers with rateable remuneration of over $200,000 have their claims costs factored into their premium calculation. Employers with less rateable remuneration than this have their premium calculated based on the performance of the industry they operate in as expressed by the industry rate. Claims costs in themselves do not directly increase or decrease an employer s premiums. Claims costs are used to determine an employer s performance rating that is then used in the calculation of the employer s premium rate. An employer s performance rating (their EPR ) is a comparison of their claims costs relative to those of their industry. In the calculation of an employer s EPR their size is used to measure them relative to their industry and the total claims costs for the industry so they are compared to the average. Those performing better than average will be rewarded with a lower premium rate and conversely those performing worse than average will see their premium rate set higher than it might otherwise be.

3 More on the Estimating Model WorkSafe uses claims data to determine a Statistical Case Estimate (SCE / estimate), providing for a more consistent and objective approach to the estimation process. Estimates are used to provide a means of measuring the severity of injuries through the full cost of a claim. They allow for claims in each year to be weighted equally, if no estimate is used older claims would have a greater weighting as they have more actual payments and all other factors being equal every dollar paid would have a greater impact on premium. The SCE model is a particular type of predictive claims model which provides individual estimates of future claim costs arising from existing claims. These estimates are predicted via a statistical model using the individual characteristics of each claim. Predictive claims models are useful because they implicitly link underlying drivers to outcomes of interest at the individual claim level. The models themselves help to perform three key tasks: - Provide a stronger link between changes in the claims processes and reserving; - Provide estimates of future claims costs arising from existing claims; and - Provide an understanding and quantification of the drivers of a claim. Past payment levels is also generally a good predictor of the likelihood of future payments, and form one of the key model drivers. They form the basis for determining whether a claim is currently receiving weekly benefits ( on benefits), or not ( off benefits). Moving from on benefits to another month of being on benefits gives rise to a higher probability that benefits will continue. What this means for the employer Although the value of the estimates may appear higher under the estimation model, this does not necessarily imply a dramatic effect on an employer s premium. This is because the claims costs are used to determine an employer s relative performance that is, how an employer s claims costs compare to their peers. An employer s estimates are also used in the claims experience of their industry it is the ratio that is important. This means that an employer s claims estimates are compared with the estimates for all other employers in their industry (or industries) with all estimates made using the same consistent and objective method. Accordingly, the chance of an employer being disadvantaged by the use of modelled estimates is significantly reduced. To assist with an understanding of the estimating process, answers to the following potential questions have been prepared: 1. Why are there changes in estimates in March and October that are not related to changes in the individual claims? WorkSafe s estimation model provides for an objective, consistent and relative measure aligned to scheme experience. To ensure that the model reflects scheme experience and scheme trends it is recalibrated and adjusted twice a year following actuarial valuations of the Scheme. Recent scheme experience may suggest that claims with certain characteristics have a higher probability of incurring further payments, whilst others have a lower probability. The model is recalibrated and adjusted to reflect these trends, looking at the interaction of all the characteristics in determining the estimated future costs for each claim, which will change from month to month as the claim develops. Not all claim variances are due to model recalibrations. Monthly variations to the claim estimates will typically reflect changes in claim characteristics, such as coding and payment status. Reductions to estimates generally occur when sustainable return to work has been achieved. The effect is not immediate hence return to work outcomes need to be sustained.

4 It is important that employers are aware of how claims costs are used to determine their performance, essentially how their claims costs compare to their peers. The estimates for a particular claim are also used in the claims experience of the industry and it is the relativity between the employer and the industry as a whole that is important. This means that for employers, claims estimates are compared with the estimates for all other employers in that industry with all those estimates made using a consistent objective method. This means that the chance of an employer being disadvantaged by the use of modelled estimates is significantly reduced. 2. Why do inactive claims continue to have estimates? While a claim may be inactive that is, no payments have been made recently based on the experience of the scheme a significant percentage (approximately 30% over a three year period) of claims re-open and incur further costs. There is no way of knowing exactly which ones will be re-opened, so an estimate continues to be calculated on inactive claims in the scheme to reflect this possibility by applying a probability that the inactive claim will reopen. However, this estimate is lower than it would be if the claim was still active because the probability of the claim reopening is comparatively small and will reduce further the longer the claim stays inactive. If a claim does come back on benefits the estimate on the claim is likely to increase. Counterbalancing the probability applied to inactive claims that they will reopen, is a probability applied to active claims that they will close. 3. Why is there still an estimate calculated for a worker who no longer works for the employer? A worker s legal entitlement to compensation for an injury is not extinguished if they leave or change their employment. The connection between the claim and the employer s policy remains intact no matter if the worker continues their relationship with the employer or not. If a worker with a claim has resigned or is no longer employed by the injury employer, the claim may still have an estimate of future costs. This reflects the possibility that the claim may be reopened through appeal, or deterioration of the worker s condition. 4. How are rejected and terminated claims treated by the model? If a claim has been rejected and no compensation (weekly benefits or standard medical expenses) has been paid then it will not have an estimate used in the calculation of the employer s premium. In past years the practice was to include rejected claims with any payment made (i.e. liability has been denied by the employer and the Agent has rejected the claim) because of the potential for the claim to reopen and incur future costs. It was recognised that this only occurs for a very small minority of claims so the need for an estimate to be included was outweighed by the probability of no further costs being incurred by the claim. From 2010/11, claims have only had estimates applied for premium purposes where compensation has been paid. Claims with only investigation costs (i.e. the costs associated with determining liability including investigation and claim management) will only have actual payments incurred used in the calculation of the employer s total claim costs. For any claims where there has been a payment of benefits an estimate will be calculated and applied in the determination of the total claim costs. 5. The claim has been settled but an estimate continues to be calculated? If a worker has formally withdrawn their claim, or it has been settled, an estimate will still be calculated. This relates to both settlements (under sections 115, 116 and 117 of the Accident Compensation Act 1985) and common law settlements, where the estimate for compensation and common law is set to zero. However, these claims may still attract an estimate for future medical or legal expenses as these settlements do not preclude the worker from claiming for these future costs.

5 Historically, a certain proportion of claims that are rejected, terminated or withdrawn will attract future payments, particularly medical, legal and common law payments. In some instances the claims may be reactivated by legal action or a determination. Therefore, as some of these claims are likely to incur a future cost, and there is no way to predict which claims these will be, a proportion of the expected costs are allocated to each of the claims. 6. Why do estimates continue to be calculated once retirement age is reached? Retirement age (based on the worker s date of birth) is one of the variables taken into account by the model, and factored in throughout the estimating process for a claim. It is therefore not expected that an estimate would drop significantly when retirement age is reached and weekly payments cease. Payments may still be incurred after a worker retires and an estimate of future costs is calculated taking these payments (e.g. medical services) into account. 7. The worker has died but an estimate has still been calculated? If a worker dies, an estimate of future costs will not be applied; however the date of death needs to be recorded by the Agent. Where this has not occurred, an estimate will continue to be calculated and applied. 8. Are non-negligent third party TAC claims excluded for premium purposes? Generally, when WorkSafe Victoria recovers funds from a third party, an employer s claims costs for premium purposes are reduced by the amount of the recovery. When recovering from the TAC the situation is somewhat different. From 2007/08 onwards, any claim with TAC recoveries under section 137(5A) of the Act that was recorded as involving a negligent third party prior to the claim costs extract date in early July, will not be used in the employer s premium calculation. Where there is no negligent third party associated with a claim any recoveries made from TAC are not taken into account. Rationale Where a worker is involved in a car accident, the cost of the claim is removed from an employer s premium calculation where a negligent third party was involved. If the cost of the claim was offset in all cases, there would be a reduced premium incentive to ensure the safety of workers and maintain emphasis on return to work. For example, if a worker is using a piece of equipment in a workplace and the worker is injured, the compensation costs of that injury are included in the employer s premium calculation. If the injury was due to a failure of the machinery due to the negligence of the manufacturer then a recovery may be possible and any amount recovered would offset claim costs included in the premium calculation at the time the recovery is made. However, if the injury was caused for any other reason and the machine manufacturer was not negligent, there would be no recovery and none of the costs of the claim would be reduced. Work related motor vehicle accidents are treated in the same way with an offset of the recovery only applied if the injury is caused by the negligence of a third party. In instances where the TAC makes a payment to WorkSafe Victoria for non- negligent third party claims, the benefit of these payments is applied across all employers through the industry rate calculation. This is reflected in the industry rates and overall scheme premium rates but not individual employer premiums, maintaining safety incentives and ensuring that they are not reduced.

6 9. Why are there different estimates assigned to the same injury for two different claims? Two claims with identical characteristics will have the same estimate calculated; however the chances of all characteristics being identical are small. It is possible for two claims to be lodged for the same individual with the same or similar injury type, however if the characteristics are not identical for each claim the estimates will not be identical. If different payment types are made on each of the claims this will mean that they are not identical. The level and types of payments may differ, along with the timing of the benefits being delivered, which can also impact the size of the estimate. 10. Why is the coding on claims important? The estimation model relies on the accuracy of the data supplied by the employer to the Agent and then entered into the claims management system. If deemed necessary, a review of the coding on the claims in question should be undertaken by the Agent to ensure that the coding reflects the facts of the case / cases referred to by the employer. It is important to note that any changes made to the coding on a claim have the potential to impact on the estimate, causing possible increases or decreases, depending on the interaction of the clam characteristics. 11. What happens if the data on the claim was incorrect as at the claim cost extract date? Errors in data as at the claim cost extract date should be corrected and the procedure below dealing with amendments to estimates following the loading of the SCE file must be followed, with the same process also applying to changing payment errors. If an Agent identifies circumstances that are not covered by this procedure, the Agent itself (through the State Manager) should refer the matter to the Director Premium at WorkSafe Victoria. The referral must include a recommendation and supporting documentation. Amendments to estimates following loading of the SCE Premium file i. Claimant proven not to be a worker In circumstances where: a) An employer has alleged (prior to the date of determination of costs of claims) that a claimant was not a worker; and b) The claimant has been proven to be a non-worker, at the time of injury, through a court or tribunal, and thus not entitled to compensation under the Accident Compensation Act 1985; and c) The period in which the claimant can appeal the decision of the court or tribunal has expired without an appeal being lodged by or on behalf of the claimant. The estimate in respect of the claim may be deemed to be zero, in respect of 2013/14 premium calculations. However, the estimate may not be deemed to be zero until appeal processes available to the claimant have been extinguished by either process or time. If the appeal process is finalised after the date of determination of costs of claims the estimate may be deemed to be zero at that point, and the premium reviewed under sections 22 or 27 of the Accident Compensation (WorkCover Insurance) Act In these cases the estimate may only be adjusted by the Authority itself, and an Authorised Agent on becoming aware of such a matter must refer the case to WorkSafe directly along with all relevant supporting evidence. ii. All other Circumstances Once the premium claim cost for a claim has been calculated amendments to the SCE component of the cost of a claim will only be made if - a) the correct information was in the possession of WorkSafe (or its Agent) as at the date of determination of cost of claims; and

7 b) the information relates to a claim which is taken into consideration for the purposes of calculating the employer's premium for the 2013/2014 policy period; and c) by reflecting the correct information in the claims management system data there is as a consequence a significant adjustment to the estimate of future costs in respect of that claim (which will be judged by reference to the monthly SCE calculations). Where an amendment to any premium claim cost record is to be made by the Agent an the State Manager of the Agent must authorise in writing that a premium claims cost adjustment may be made. The Premium Division within WorkSafe will monitor claims cost adjustments to ensure that the functionality is being used appropriately. In the event that the Director, Premium determines that an adjustment is not appropriate under these procedures, the Agent will be directed to reverse the Adjustment. 12. Why do we use a 3 year claim reporting period? In order for an employer s premium to be calculated in a way that recognises their health and safety and return to work records we use a limit on the amount of history used in establishing their performance. The claims reporting period is the timeframe we use to capture an employer s history. The 3 year claims reporting period provides a balance between premium being responsive to an employer s health and safety and being exposed to the volatility that they may experience if the period was only one year. By having the 3 year period employers will have a degree of stability in their premium rate that 1 or 2 years would not provide. 13. Why are industry rates determined based on a five year period? Industry rates are determined using the five policy periods prior to the preceding policy period. This allows for a complete picture of the industry to be established (as information relating to the preceding policy will not be fully known until some time after the end of the period) and to provide a stabilised measure of the cost of the industry to the scheme that provides for recognition of sustained change across the given industry.

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