HPSS INJURY BENEFIT SCHEME

Transcription

1 HPSS INJURY BENEFIT SCHEME APPLICATION FOR PERMANENT INJURY BENEFIT HPSS INJURY BENEFIT SCHEME ANENT INJURY AWARD

2 (Please complete Part1 and return it to your Employer) PIB1 06/09 (Please complete Part 1 and return it to your Employer) PIB1/04/03

3 Important Notes for Applicants Please Read Carefully Permanent Injury benefit will only be payable if you have sustained an injury or contracted a disease which is wholly or mainly attributable to your HSC employment, resulting in a permanent reduction in earnings ability of 11% or more. The award of Injury Benefits is subject to review if you qualify for sickness benefit, incapacity benefit, industrial disablement benefit, reduced earnings allowance or any other related benefits. If you are awarded such benefits or there is a change in the rate (other than the annual increase) whilst you are in receipt of injury benefit you must notify this office. The Department may require any person entitled to benefit, to submit to a medical examination at a future date. Please note that any Injury Benefit paid may be recoverable from damages/compensation awarded from a claim made in respect of your injury. You should notify HSC Pension Service if such a claim is made, or a pending claim is settled. If you take up any employment again you must notify this office immediately. APPLICANTS SHOULD COMPLETE AND SIGN THE FOLLOWING: Part 1 of the application Form The Applicant s Declaration The Employee Consent Form THE APPLICATION FORM SHOULD NOW BE FORWARDED TO YOUR EMPLOYER FOR COMPLETION OF PART 2.

4 Part 1 APPLICATION FORM Name: (BLOCK CAPITALS) Place of work: Payroll Number: Home Address: Bank Details: Date of Birth: Job Title: Daytime Telephone No: Postcode: National Insurance Number: Date of Injury/Disease: Nature of Injury / Disease Have you previously suffered from this injury or disease? i.e. before the above date. * Yes / No (if Yes give details with dates) Briefly state why you believe your injury / disease to be wholly or mainly attributable to work; Have you made a claim for damages against your employer, or a third party because of your injury/disease? *Yes/No. Please give full details of your solicitor. Name: Address: Telephone No:

5 Has a claim been made to the compensation agency because of your injury/disease? *Yes/No Please give their reference number:- Reference No: Are you claiming or are you awaiting the outcome of a claim for any of the following Social Security Benefits? (Tick as appropriate) Incapacity Benefit Severe Disablement Allowance Industrial Injuries Disablement Benefit State Retirement Pension Income Support Employment & Support Allowance Reduced earnings allowance Applicants MUST make a claim for any of the above benefits that may be payable. Are you working anywhere at present? *Yes/No If Yes, provide details below. (Details should be provided of all employments if more than one). Who is your employer? What job are you doing? How many hours per week do you work? What are your gross earnings? *Delete as appropriate Please provide details of all HSC Employments:

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7 EMPLOYEE CONSENT FORM You have applied for an Injury Award under the HPSS Injury Benefit Scheme (Northern Ireland). In order to consider your application it may be necessary to obtain further information from the following: Occupational Health Records (if applicable) Welfare Officer Report (if applicable) General Practitioner notes Consultant Specialist Report (if applicable) Your Name: Date of Birth: I agree to the administrators of the HPSS Injury Benefit Scheme and their Medical Advisers having access to or obtaining reports from the Welfare Officer and the HSC Occupational Health Department. I also agree to their Medical Advisers having access to or obtaining reports from the sources listed below, as well as any other benefits office. In so doing I understand that the information provided will only be used to determine my application for an award under the HPSS Injury Benefit Scheme. Name of Occupational Health Doctor: Address: Post Code: Name of General Practitioner: Address: Post Code: Name of Hospital Consultant (if more than one please specify): Address: Post Code: Signed: Date: Please ensure this consent form is fully completed and submitted with your application.

8 Declaration for Applicants I wish to apply for HSC Permanent Injury Benefit, on the basis that I have sustained an Injury or Disease, which is wholly or mainly attributable to my HSC employment I declare that all of the information I have given on this form is true, complete and accurate to the best of my knowledge and belief, and I acknowledge that I must notify HSC Pension Service of any changes in circumstances as set out on this form I understand that if I supply information to the HSC Pension Service, which is false or misleading in any material particular, I may be prosecuted for a fraud offence. Signed: Dated:

9 Important Notes for Employers Please Read Carefully Please ensure the applicant has: - Fully completed Part 1 Completed and signed the employee Consent form Signed the Declaration for Applicants Part 2 of the Application Form gives Employers the opportunity to comment and provide details regarding the applicant s injury and the circumstances surrounding it. Please note that Employers must complete the Key Work Task boxes in Section 5 of this form before an application can be processed. (HPSS Superannuation Branch s medical advisers will complete the Impairment level boxes) The Key Work Tasks are required to provide guidance to the Medical Advisers as to the functions the applicant performs on a regular basis. A job description will not be accepted as a substitute for the Key Work Tasks. One of the Key Work Tasks for every applicant will be mental capacity and intellectual functioning, this has been completed for you. We appreciate that this may prove time consuming for Human Resource Personnel, but the Department feels this is necessary to ensure claims are properly processed. Failure to complete the Key Work Tasks at Part 5 will result in the Form being returned to Employers and as a result will delay the application process. After Parts 2 and 3(if applicable), and the Key Work Tasks at Part 5 have been completed, Employers should forward the application form to HSC Pension Service.

10 Part 2 MANAGEMENT REPORT Employers MUST also complete the Key Work Tasks at Part 5 of the application Form. Has the applicant applied for Temporary Injury Benefit? Was the application successful *Yes/No *Yes/No The Management Report MUST briefly state the management view on the applicant s reasons for stating that their injury/disease is wholly or mainly attributable to work. Sick Leave records should be provided, Management View (Please state below). Employer Statement on Application 1. Did the applicant make his / her line manager aware of the injury/condition as outlined. *Yes/No 2. Confirm if an incident or accident occurred and that the applicant was involved and give relevant dates below. (Accident report must be provided if applicable) * Yes/No 3. Confirm that the work-related issues are accepted as part of the nature of the duties. Any Other Details: * Yes/No Cont.

11 MANAGEMENT REPORT (continued) If feelings of stress were advised to you, what action if any was taken? If the applicant has not previously given notice of the injury / condition, line management should comment on the points cited in the application. Name: Grade: (Block Capitals) Signature: Date: Contact telephone no. Office Stamp: *Delete as applicable

12 Part 3 STAFF CARE / WELFARE OFFICER REPORT (If Applicable) Give details of Welfare involvement As far as you are aware are there any issues outside of the work environment that could be relevant to the causation of the condition stated in Part 1: * Yes / No (if Yes give details) Signed: Date: Name: *Delete as applicable

13 Part 4 HPSS Injury Awards Assessment Form The following is for the information of Examining Medical Officers The HPSS Injury Benefit Scheme provides for payment of an injury award, which compensates for impairment of earnings, if any person (whether they are members of the pension scheme or not) is injured in the course of performing their duties. Qualifying Conditions Permanent Injury Benefit is payable to a HSC employee or former HSC employee if, because of an accident, disease or condition which is wholly or mainly attributable to their HPSS employment they have to: - (i) (ii) Leave work altogether. Reduce their hours of work permanently. (iii) Take up lower paid employment on a permanent basis. Benefits will not be payable if the said injury or disease, or aggravation, is wholly or mainly due to or is seriously aggravated by his/her own serious and culpable negligence or misconduct. Important Notes 1. If the injury is not likely to be permanent no award will be made. 2. The purpose of this is to determine the effect the injury (excluding other health problems) had on the member s ability to carry out his / her full range of duties and therefore determine an earnings impairment. 3. Injury awards payable are entirely separate from the injuries accepted by the Social Security Industrial Injuries Scheme. 4. The injury/disease must have been caused as a result of their HPSS employment. 5. If the member is suffering from a disease which they allege has been caused by their employment in the HSC, care should be taken to ensure that the disease could not have been contracted in a previous employment. (A full employment history will be supplied in these cases).

14 To be completed by HSC Pension Service - Injury Benefit Supervisor (EO2) The following additional papers are attached: (tick as appropriate) Accident Report Witness Statements Sick Leave Records Medical Evidence: - GP Report/Notes Employers Occupational Health Report Consultant Report Full employment History (in industrial diseases)

15 HSC Pension Service - Summary of Application (Prepared by AO)

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17 Name: Date: HSC Pension Service Injury Benefit Supervisor (EO2)

18 Information available to make the assessment: To be completed by NICS OHS Medical Adviser Nature of Injury / Disease cited by applicant: Did the applicant suffer from this Injury / Disease? *Yes/No (if No give details) How does the applicant relate their Injury / Disease to be wholly or mainly Attributable to work? Does the Management Report support the wholly or mainly attribution to work? * Yes/No (if No give details) *Delete as applicable Continued :-

19 CONCLUSION STATE REASONS AS APPROPRIATE (a) The Injury and/or Disease Has the applicant suffered from an Injury or medical condition: * Yes/No Does applicant have a previous history of this injury / disease: *Yes/No (b) The Attribution to work: Uncertain that the work-related issues as stated by the applicant are part of their duties. Employer must determine. In my opinion the applicant s Injury or disease * is / is not wholly or mainly attributable to their duties. Signature: Date: Name: Note: Complete Part 5 if the applicant has a Qualifying Injury. Medical Adviser to enter clinical code for OHS use only *Delete as applicable

20 Part 5 Assessment of Earnings Impairment Medical Key Work Tasks to be completed by Applicant s Employer If the injury is not likely to be permanent the impairment level boxes do not need to be completed. Type of application: *Initial/Appeal/Deterioration Name: Reference Number: Date of Retirement: Job Type: *Nurse/Ambulanceman/Clerical/Manual/Other Job Title: (*Delete as appropriate) Please indicate below the degree by which the applicant is unable to carry out the key work task as shown in their job description. Key Work Task To be completed by Employer. 1. Total Impairment Level Tick One Box In Each Key Work Task To be completed by OHS Severe Moderate Mild Not Appreciably 2. Total Severe Moderate Mild 3. Not Appreciably Total Severe Moderate Mild Not Appreciably

21 4. Total Severe Moderate Mild Not Appreciably 5. Mental capacity and intellectual functioning with regard to their own/last job. Total Severe Moderate Mild Not Appreciably