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NHS INJURY BENEFITS SCHEME - Notes for Guidance - PDF
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1 NHS INJURY BENEFITS SCHEME - Notes for Guidance Purpose of this Guidance This leaflet provides both general and detailed information and guidance for NHS employers, applicants and reporting doctors for submitting an application for Permanent Injury Benefits (PIB). It comprises five sections: Section 1 Section 2 Section 3 Section 4 Section 5 Provides general information that all users are advised to read Explains the role of NHS Pensions Explains the role of the NHS employer Explains the role of the applicant Provides question by question guidance for all contributors in completing the form AW13. SECTION 1 General information for all users NHS Injury Benefits are available to almost all NHS employees. There are a few exceptions such as GP Practice staff, GP Co-operative staff and a special group of employees called Direction Employees. If you are unsure, ask NHS Pensions for advice. Employers must do all they can to identify cases and submit an application where Permanent Injury Benefits may be appropriate. As the Scheme is part of the terms and conditions of service for most employees, employers cannot deny the making of an application unless the employee is one who is not covered by the Scheme. Purpose and requirements of the Scheme The NHS Injury Benefit Scheme is a no-blame income protection scheme intended to top-up income of successful PIB applicants between 15% and up to a maximum of 85% of previous NHS earnings. The Scheme does not protect extra payments such as one-off bonuses or overtime. Neither is it intended to provide direct compensation for Illness or injury. The Scheme requires that three criteria are satisfied: Firstly, the applicant must be employed by the right type of NHS employing authority. Secondly, the applicant must have suffered an injury or contracted a disease that is:- a. Sustained in the course of their employment and which is wholly or mainly attributable to that employment, or b. Wholly or mainly attributable to the duties of that employment. Third, the applicant must have suffered a permanent loss of earning ability in excess of 10%. For this purpose permanent means to age 65. Not all applications will result in benefits being awarded. More information is available on the website at and in the booklet SDIB entitled NHS Injury Benefit Scheme available in hard copy from employers or downloadable from NHS Pensions website library. NHS Injury Benefits Scheme - Notes for Guidance (V2) 01/2011
2 SECTION 2 Role of NHS Pensions NHS Pensions, via its medical advisers, is responsible for administering the NHS Injury Benefit Scheme on behalf of the Secretary of State for Health under the provisions of the NHS Injury Benefit Regulations 1995 (amended). A full copy of the Regulations can be viewed or downloaded free of charge from NHS Pensions website library at: NHS Pensions will determine whether an applicant is entitled to PIB and if so, the level of benefit they will receive. Applicants who are dissatisfied with the outcome of their claim have a right of appeal, which will be fully explained at the time. NHS Pensions or its medical advisers will keep both the applicant and their employer informed of progress whilst processing the application. On completion they will issue a formal decision letter to both. Where the application is unsuccessful we will provide the applicant with an explanation of how the decision was reached and details of appeal opportunities. In considering each claim NHS Pensions must consider all relevant evidence and weigh that evidence accordingly. The weight to be attached to each piece of evidence is for NHS Pensions to decide. In addition to the information presented with the application, NHS Pensions may obtain further information/evidence it deems necessary in order to have as full a picture as possible. This may include the applicant being examined by an independent medical expert or functional analyst. Having decided that the applicant is employed by the right type of NHS employing authority, when NHS Pensions is satisfied that it has as much relevant evidence/information as it needs in order to make a decision it will, in the first instance, decide whether the applicant meets the attribution test. i.e. whether they have suffered an injury or contracted a disease that is:- (a) Sustained in the course of their employment and which is wholly or mainly attributable to that employment, or is (b) Wholly or mainly attributable to the duties of that employment. Applicants may sometimes claim for more than one injury or disease so it is important that we have all the relevant information. NHS Pensions takes advice on medical matters from a panel of professionally qualified and experienced occupational health physicians, who also have access to specialist input/advice where necessary. When NHS Pensions is satisfied that the applicant meets the requirements of the attribution test it will begin to assess the degree of Permanent Loss of Earning Ability (PLOEA), which, in turn, will contribute to determining the level of benefits payable, if any. SECTION 3 Role of the employer Injury Benefits (IB) are part of the Terms and Conditions of NHS employment. It is the employer s responsibility to ensure that they have a proper and open system in place to identify situations where a claim for Injury Benefits might be appropriate and to initiate the claims process. Those involved in the employer role eg. managers, supervisors, pay, pension and human resources personnel must do all they reasonably can to identify possible cases and make staff aware of their rights to claim Injury Benefits. You must issue a PIB application form AW13 and complete Part A. Further guidance and information for employers and employees is available on the home page of NHS Injury Benefits website at Failure to provide any of the information required will result in a delayed decision. 2
3 We need as much information as possible about three specific areas: The injuries sustained or the disease contracted by the applicant, its treatment and prognosis. How that is connected to their NHS duties (i.e. what caused it) How or whether the injury or disease has caused a permanent reduction in earning ability In all cases: you must include with the application, copies of All accident reports. All Occupational Health Department notes and records. Reports of any internal investigation connected with the claim. A full job description. Sick leave records A full statement of events explaining what injury or disease the applicant is claiming for and the circumstances leading to the claim, i.e. how the injury or disease is connected to their NHS work. Employers who do not support the claim must still provide a statement, and in these cases, it would be very helpful if you explained your reasons for not supporting the claim. Regulation 18A of the NHS Injury Benefit Regulations requires that Employing Authorities provide whatever information NHS Pensions needs to process a claim. Section 5 of this guidance provides more information to help you complete your part of the application form. SECTION 4 Role of the applicant In order to deal with your claim properly and quickly it is vital that we have as much information as possible about your injury or disease, its onset, cause, effect on you and your ability to work, and the prognosis. The form AW13 contains two Parts. Your employer must complete Part A and you must complete Part B. We would strongly recommend that you provide us with a statement explaining in your own words what has happened [describe the incident(s) or accident(s)], how that has injured you [what injury or disease are you suffering from as a result] and what effect that has on your ability to work and carry out your daily activities. Also please check the information provided by your employer at Part A and any other accompanying documentation they have provided. You cannot alter anything your employer has provided, but if you disagree with any of the information they have given us, tell us what you disagree with and why. Lastly, please let us have copies of any documents or reports that you think support your claim. Do not send originals if you can avoid it. If you do not have certain documents or reports that you would like us to see, but you have the contact details of where we can get them, please give us the details and we will do our best to obtain them. The following are suggestions for useful information you may wish to let us have, which will allow us to consider your claim. Please do not feel overwhelmed by the following list. Not all of course, will apply to you. Part of the process may include seeking your consent for medical evidence, which we will obtain from your GP, specialists and occupational physician if we do not already have it from yourself or employer and a medical adviser looking at your claim considers this is appropriate. If you 3
4 can help with supplying additional evidence where it does apply to you it will be very useful. For applicants who have had an accident at work: If you had more than one injury include documentation about each if you have it. If you had a physical, psychological injury or both, as a result of an incident or series of incidents at work, which was recorded in the accident book, please include a copy of that form if your employer has not already done so. Your employer should be able to help you obtain a copy. If you sought an accident declaration by the Department for Work and Pensions [DWP] or formerly the Benefits Agency [BA] or DSS include a copy of that. The DWP can help you obtain a copy of the declaration, and if you have claimed Disablement Benefit, you may also ask them for copies of the medical assessment papers. If you had an accident at work, and did not have it entered in the accident book, but a colleague witnessed it, include a signed statement from that witness if you can. If you cannot remember the exact date of an accident or incident at work and it was not recorded or witnessed but you attended your GP, they may be able to confirm that attendance and the date from their notes. If you attended A&E, they may have sent your GP a discharge summary. If you attended Occupational Health following the injury, they may also be able to help with dates and details. If you have already been awarded Temporary Injury Allowance [TIA] and have any relevant documents about it, it would be useful to let us have these too. If you have sought compensation or damages and have evidence, such as expert medical reports, or details of judgements and outcomes, which may be helpful relating to this, please include them. For applicants who consider they have contracted an illness or disease at work: If you have contracted a notifiable infectious disease such as hepatitis or tuberculosis you are likely to have documentation from your Occupational Health and/or Public Health Departments confirming this. If you have contracted an occupational disease, which is also a prescribed disease under the DWP Industrial Injuries Scheme Benefits, such as occupational asthma or dermatitis, and it has been accepted and assessed as such it will be useful to let us have copies of the DWP documents of acceptance, assessments and awards if you have them. If you do not already have them you may be able to request them from the DWP. If you think you have suffered some kind of psychological or mental health injury because of your work, it is important to include any documents that can give the views or perspectives of other people who perhaps witnessed or were involved in the situation. For instance you may have: A colleague who can give you an account from their perspective. Copies of letters and/or s in which you have expressed your concerns about an adverse situation. For instance, to your manager or HR or Union rep, perhaps about overwork, poor relationships, lack of support or resources or equipment, the pace and degree of change affecting your role and duties, delay in handling your concerns, or perhaps about the effects of the adverse situation on your health. Documents relating to a complaint or grievance you may have raised, and how this was investigated or resolved. A Union rep is often involved, and that person may be able to help you 4
5 gather this documentation. If you have a work-related condition, such as work-related upper limb disorder [WRULD], which has been assessed by occupational health by way of workplace assessment, with various adjustments to your pattern of work and the provision of additional equipment, you may have documents that confirm such activity. If you have already been awarded Temporary Injury Allowance and have any relevant documents about it, it may be useful to submit these. If you have sought compensation or damages and have evidence such as expert medical reports, or details of judgements and outcomes, which may be helpful relating to this, then it will be useful to include it. N.B. It is not necessary to prove that your employer was at fault to get Injury Benefit; it is a noblame scheme. Section 5 of this guidance provides more information to help you complete your part of the application form AW13. SECTION 5 Completing the application form AW13 The applicant s employer will complete Section A. The applicant will complete Section B. PLEASE COMPLETE THE FORM USING BLACK INK Section A To the employer Part 1 Q s 1 6. Insert the applicant s personal details. If you already have an IB reference number for this applicant, in relation to a TIA claim please show it at the top of the front page. Q7. Tell us the applicant s number on your payroll. Q8. We need to know if the applicant is a member of the NHS Pension Scheme or some other private scheme or plan and the scheme reference number. Q9. We may already have obtained information in connection with an ill-health retirement pension application that would be useful in considering this application, so please tell us whether an application has been accepted. Q10. Different regulations and criteria apply to this application depending on what has happened as a result of the work related injury or disease. Please tell us whether the applicant has terminated employment with you, moved to lower paid employment (this includes moving to part-time), or has died, and the dates. Part 2 Complete Part 2 only if the employment has ended or the applicant has moved to lower paid employment. Q1. Tell us what the applicant s job was before the termination or change. Q2. We need the full name and address of the place of employment, including the name of the PCT/ LHB or Trust. Q3. Please tell us if the employment was part-time and if so the part-time and standard whole-time hours. 5
6 Q4. It is important that we have as much information as possible about the applicant s working life. Please tell us what you know about any other NHS employers they previously worked for and when, including details of any pre 1974 Local Government employment with Scotland, Northern Ireland or the Isle of Man. Q5. We need as much information as possible about all sick leave relating to this application so that we can map the onset and any progression of the condition claimed for. Q6. It is very important that we have accurate pay information. The figures to be shown are the same as pensionable pay. Q7. It is very important that we know if TIA has been awarded. Complete the next question only if the applicant has changed to lower paid employment. Q8.(a)-(f) It is important to let us know whether the applicant has remained in the same job, but reduced their hours or if they have changed jobs completely. Q9. The Scheme s Regulations require that any damages or compensation in respect of the same injury or disease shall be deducted from any PIB that becomes payable, so it is important that we have Solicitor s details to deal with this if an action has been taken out. Part 3 Complete Part 3 only if the applicant has died as a result of the injury/disease being claimed for. Qs 1-6 A lump sum and/or allowance may be payable if the deceased applicant left a legal spouse, dependent children or a relative who was financially dependent on them when they died. This can include parents, parents-in-law, siblings, children, stepchildren or grandchildren. If you are unsure whether the relative may qualify, tell us about them and we will investigate. Part 4 (a) (b) Applies to death cases only In all cases please send us copies of the following. Do not send originals if you can help it. All accident/incident reports, IB 76 All Occupational Health department reports and notes A full job description for the job the employee was doing before the accident/ incident. Any internal investigation or disciplinary reports connected with this claim. In cases involving mental health conditions: A statement explaining what injury or disease the applicant is claiming for and the circumstances leading to the claim. i.e. how it is connected to their NHS work. Declaration and signature The application cannot be processed unless it is authorised by a signatory for the employer such as the Payroll Manager or Human Resources Manager, or is not stamped. Please show your contact details clearly so that we can get in touch with you quickly if we need to. You have now completed your action on this application form. Please pass it quickly to the applicant for them to complete Part B. Don t forget to include all appropriate documents and envelope MP Env 90. 6
7 Section B To the applicant Part 5 Q1. It is in your best interests to check what your employer has told us at Section A and any enclosures they have included. If there is anything you do not agree with, tell us what it is and why you do not agree. We can then investigate further if we think we need to. Q2. The Scheme s Regulations require us to take into account certain benefits paid by the DWP. It is very important that you tell us whether you are claiming, awaiting the outcome of, or appealing any claim, and the details of the office dealing with that claim so that we can check your payments etc. Failure to do this may result in an overpayment of your PIB that you will have to repay. Q3. If NHS Pensions accepts that you have suffered an injury or contracted a disease that is:- (a) Sustained in the course of your employment and which is wholly or mainly attributable to that employment, or is (b) Wholly or mainly attributable to the duties of that employment We will then assess your Permanent Loss of Earning Ability (PLOEA) by identifying what other alternative job in the general field of employment you might be capable of undertaking before retirement. Knowing what qualifications you have will help us to do this. N.B. It is important to understand that we will assess what job you might most likely be able to do before you reach retirement age; NOT what you can do now. Q4. For the same reason, it is also important that you tell us if you have started working again, and what work you are doing since you left your NHS job. Qs 5 & 6. These questions are very important! You cannot receive all of any damages or compensation you recover from any source, [including the Criminal Injuries Compensation Authority (CICA)] for the same injury and all of your NHS Injury Benefits. The Scheme s Regulations require that, when working out what we can pay you we offset (take off) any damages or compensation you recover from any source for the same injury or illness as you are claiming for here. It is Important that you understand this means your benefits will be reduced and, depending on the amounts involved, may mean that you are not entitled to any payment. Only where a loss of earnings (LOE) element is clearly identifiable and delineated in the settlement the Scheme s managers may, in certain circumstances, limit the amount to be offset to that amount. If we cannot identify a LOE element we will take off the whole of the damages/compensation recovered. If you have made or are making a claim for compensation or damages please tell us here about the solicitor who is or has represented you. Important! You must read the declaration very carefully and make sure that you understand what it means before you sign it. Q7 We also have to take into account any payment received from a Personal or Private Pension, as well as the NHS Pension Scheme when calculating what you can receive from the NHS Injury Benefits Scheme. If you are not a member of the NHS Pension Scheme, or have any separate top-up arrangements, it is important that you tell us about any Personal or Private Pension arrangements that you have to avoid any overpayments that you would have to repay. Q8. Applicants often have other conditions not related to their work that they are not claiming for or that we cannot take into account when considering your claim. It is important that you tell us exactly which injury or disease you are claiming for is wholly or mainly attributable to your NHS employment and has caused a permanent reduction in your earning ability. Q9. Tell us, in your own words, as much as possible about what you think caused your injury or disease, why you think it is related to your NHS job, what has changed since the 7
8 accident/incident and how it has affected your working/personal life. Continue on a separate sheet if necessary. Q10. We sometimes need to request more, or more up-to-date, information from your treating doctors. So it important that you tell us the names and hospital addresses of all the doctors you have consulted about the injury or disease you are claiming for and your GP. Q11. So that we are sure we have received everything you intended to send us, please list all the additional documents, such as medical, investigation or accident reports that you have sent us in support of your claim. Continue on a separate sheet if you need to. Q12. Declaration & Consent Please make sure that you sign the declarations on page 9, 11 and the consent on page 13 of the form AW13. We cannot process your application without it. You have now completed your action on this application form. Please check it and then you can either ask your employer to send everything to us, or you can send it to us yourself. If they have not already done so, your employer should give you a pre-paid addressed envelope. 8