Internal Guidelines used in processing claims
Table of Contents
◊ Part 1: ENTITLEMENT
◊ QUALIFYING CONDITIONS in Summary
◊ QUALIFYING CONDITIONS IN DETAIL
- PRSI classes covered
- Date of accident or disease
- Nature of accident
- Accident by Process
- Incapable of work
- Days which are treated as days of incapacity:
- Days which are not treated as days of incapacity:
- Place of accident
- Third World volunteer workers
- Mariners and Airmen
◊ PRESCRIBED DISEASES
- Rules of Behaviour
- Disqualification on Imprisonment
- Late Claims
◊ RATES STRUCTURE
- Payments to Persons in Receipt of certain Social Welfare Payments
- Extra Benefits
- Overlapping provisions
◊ PART 2 CLAIMS, INVESTIGATION AND DECISION PROCEDURES
- Late claims
- Interim payment of Illness Benefit
- Investigation of the injury/accident
- Investigation of insurability
- Investigation of Occupational disease claims
◊ Part 3: PROCEDURES FOLLOWING AWARD
- How Payment Is Made
- Payments to Nominated Persons
- First date of payment.
- How Long Payment Lasts
- Assessment of Damages in Civil Cases
Part 1: ENTITLEMENT
Injury Benefit is a benefit available under the Occupational Injuries Scheme, and is a weekly payment made to an insured person if they are unfit for work either due to an accident arising out of and in the course of employment or due to the contraction of a prescribed disease due to the type of work they do.
The Scheme was introduced on 1 May 1967.
Note: Accidents while on an unbroken journey to or from work are covered under the Scheme. See under Section "Qualifying Conditions in Detail".
Injury Benefit SW 30
Prescribed Occupational Diseases SW 33
The main legislation relating to Injury Benefit is contained in
- Chapter 13 of Part 2 of the Social Welfare (Consolidation) Act 2005, as amended, and
- SI No 102 of 2007 (Social Welfare (Consolidated Occupational Injuries) Regulations 2007, as amended.
The Benefit is administered by the Injury Benefit Section, Department of Social Protection, Áras Mhic Dhiarmada, Store Street, Dublin 1, (01) 7043300.
The person must have been in employment under any contract of service or apprenticeship which is insurable at Pay Related Social Insurance (PRSI) classes A, D, J or M (where the employee is under 16 years of age) when the accident happened or the disease was contracted. But see below in relation to PRSI Class B contributors.
The accident must have occurred or the prescribed disease must have developed on or after 1 May 1967.
The accident must have happened or the prescribed disease must have developed out of and in the course of insurable employment.
The person must be incapable of work for at least 7 days as a result of the accident or disease. However, a person who suffers an accident at work but who is not incapable of work for at least 7 days is entitled to a declaration that an occupational accident occurred. This safeguards the person's future rights to benefits under the Occupational Injuries Scheme.
The accident or disease must normally have occurred in or been contracted in the State or in another EEA country if employed by an employer based in Ireland and paying PRSI contributions.
An accident while travelling on an unbroken journey to or from work is regarded as an occupational accident.
QUALIFYING CONDITIONS IN DETAIL
PRSI classes covered:
A. Person must be in employment insurable at PRSI classes A, D, J or M (where the employee is under 16 years of age)
A person must be insurable at one of these PRSI classes on the day of his accident or the date of development of a prescribed disease. Insurability under the Social Welfare Acts depends on the type of employment contract (See separate guideline on "Scope" ). Self-employed persons are not covered for Injury Benefit.
Persons insured at PRSI Class B are not eligible for payment of Injury Benefit but may be entitled to a declaration that an occupational accident occurred and may qualify for other benefits available under the Occupational Injuries Scheme.
B. The accident must have occurred on or after 1 May 1967 or the prescribed disease must have developed on or after 1 May 1967.
The Occupational Injuries Scheme was introduced from 1 May 1967. It provides insurance against accidents which occurred or prescribed occupational diseases contracted while in insurable employment on or after 1 May 1967. Occupational accidents or diseases which developed prior to that date fall under the Workman's Compensation Acts. In these cases the question of compensation is a matter for settlement between the employee and the employer.
C. The accident must have arisen out of and in the course of insurable (occupational injuries) employment.
An accident is regarded as any unexpected happening or event which results in a personal injury.
1. Where the accident arises in the course of a person's employment, it is presumed to have arisen out of that employment unless there is reason to believe that it was not caused by the employment.
2. However, an accident is also accepted as an occupational accident if it:
- was caused by another person's misconduct, negligence or misbehaviour, or
- was caused by the behaviour or presence of an animal (including bird, fish or insect,) or
- was caused by being struck by any object or by lightning,
provided the insured person did not directly or indirectly cause or contribute to the happening of the accident by their conduct outside the employment or by any act not incidental to the employment.
Other situations included:
3. One which arises although the person may not have been acting in accordance with any statutory or other regulations applicable to the employment, or in accordance with instructions from their employer, provided it would have been deemed to have arisen from the employment otherwise and the act was done for the purpose of the employer's trade or business.
4. One which arises while the person is travelling, on an unbroken journey, to or from their normal place of residence and work.
5. One which arises while the person is in or about any premises at which they are being employed for the purposes of their employer's trade or business and is taking steps, in an actual or supposed emergency at those premises to rescue, succour or protect persons who are, or are thought to be or possibly to be, injured or imperilled, or to avert or minimise serious damage to property.
6. One which occurs to an insured person, who is an apprentice, while they are in attendance at a technical school or other place for training or instruction (whether during ordinary hours of employment or otherwise), if their attendance at that school or place is with their employer's consent or is required by direction of their employer or under the contract of apprenticeship.
D. Note: Accident by Process not regarded as an Occupational Accident
Where the incapacity for work is due to innumerable unidentifiable incidents and has gradually developed over a long period, the condition results from process and is not regarded as an occupational accident, but will be examined as to whether it fulfills the condition of a prescribed disease. See later paragraph on "Prescribed Diseases".
E. Incapable of work
Days which are treated as days of incapacity:
Any day in respect of which the insured person is medically certified as incapable of work due to an incapacity which was caused by an occupational accident or of the contraction of the prescribed disease.
Note: The day of the accident can be regarded as a day of incapacity for work. This can also apply in the case of nightworkers.
Days which are not treated as days of incapacity:
- Any day in respect of which the insured person fails to prove that he is incapable of work.
- Any day in respect of which the insured person does work other than work specified in the Section headed 'Rules to be Observed and Conditions for Permission to work'.
- A day shall not be regarded as a day of incapacity for work if, in respect of that day, the insured person is being paid by their employer in respect of holiday leave.
- Sundays are not counted as days of incapacity for work.
F. The accident must normally have occurred in the State
If a person is working for an employer in another EU country or in a non-EU country with whom the EU has an agreement (Iceland, Norway, Liechenstein, Switzerland), they are generally covered by the social security laws of that country. In these cases claims for occupational accidents/diseases should be made to the Social Security Office of that country. However, if a person is sent by an employer based in Ireland to work in another country and if Irish PRSI contributions continue to be payable, cover for Occupational Injuries Benefit continues under Irish legislation.
Provisions for certain types of employments
Third World volunteer workers
Special provisions exist whereby employment abroad in a developing country where the work was arranged either through the Agency for Personal Services Overseas (APSO) or an Irish based non-governmental organisation is normally covered for Injury Benefit.
Mariners and Airmen
The employment of mariners and airmen is covered for Injury Benefit where the employment is under any contract of service or apprenticeship entered into in the State on board a ship or aircraft registered in the State or owned by an Irish employer.
Persons who are incapable of work for more than six days as a result of contracting certain diseases prescribed due to the nature of the employment are also eligible for Injury Benefit.
The diseases and relevant occupations are listed in SI 102 of 2007 and in the Information Leaflet SW 33.
njury Benefit may also be payable where the incapacity is linked to a prescribed disease (other than deafness) where evidence can be produced to show that the incapacity developed due to the employment.
See separate guideline on "Disablement Benefit" for full details of prescribed diseases, presumption of origin, date of development, and distinguishing fresh attacks from reappearance.
If a person contracts a disease from a once-off occupational accident, Injury Benefit may be payable whether the disease is prescribed or not.
Injury Benefit is not payable in respect of the following prescribed diseases: Byssinosis, Pneumoconiosis, Occupational Deafness, Occupational Asthma. In such cases Disablement Benefit may be paid from the start of the contraction of the disease.
A person may be disqualified for receiving Injury Benefit for a period of up to 9 weeks if they fail without good cause;
- to attend for a medical examination arranged by the Department.
- to accept appropriate medical treatment for the relevant injury or loss of faculty.
- to attend at such places and times as may be required for the purposes of the said medical examination or treatment
- to observe the prescribed rules of behaviour, which are outlined as follows.
Rules to be Observed and Conditions for Permission to Work
A person who is in receipt of Injury Benefit must:
- obey the doctor's instructions and answer any reasonable enquiries concerning his/her claim.
- not behave in a way which is likely to delay recovery.
- not unreasonably refuse to see an inspector of the Department
- do not do any work other than what is allowed under the regulations of the scheme, as follows:
- work which is part-time and by way of rehabilitation or occupational therapy,
- where the person has become incapable of following their usual occupation a course of training with a view to fitting themselves to take up some other occupation.
The following types of work may be undertaken without prior written permission from the Department.
(a) light work for which no payment is, or would normally be payable,
(b) work which is done as part of treatment while the person is in hospital or other similar institution and the weekly earnings do not exceed €50.00 weekly
(c) work under a scheme which is considered charitable in character where the weekly earnings do not exceed €50.00 weekly. (ref Art 75 (5) & (6) of SI 102 of 2007, as amended)
A customer cannot undertake a training or educational course or do voluntary work without prior, written approval from the Department of Social Protection. They must apply to the Injury Benefit section for this approval. From 1 January 2014 new participants on SOLAS training courses can retain Injury Benefit but cannot get a training allowance or training bonus at the same time.
Failure to observe any of the Rules of Behaviour may result in loss of Benefit.
Partial Capacity Benefit
A person cannot work while they are getting Injury Benefit, except in the limited circumstances outlined above. However, if they have received Injury Benefit for the maximum period of 6 months and have transferred to Illness Benefit, they can apply for Partial Capacity Benefit.
Disqualification on Imprisonment
A person is disqualified from receiving Injury Benefit for any period during which that person is undergoing penal servitude, imprisonment or detention in legal custody subject to the following exceptions contained in Art. 72 of S.I. 102 of 2007.
- where the person is detained on charge of a criminal offence and the charge is subsequently withdrawn or the person is acquitted and immediately before the detention, they were entitled to injury benefit
- where imprisonment is undergone as an alternative to the payment of a fine
- where the person is detained in a mental hospital (unless detained as a criminal lunatic)
Increases for qualified adults and qualified children are payable in the following circumstances:
- increases for qualified adults and qualified children are payable to an appointed person
- where the detention of the claimant is in an institution for the treatment of mental and infectious diseases OR
- if the claimant was in receipt of injury benefit immediately before being detained
- increase for a qualified adult is payable if they are detained on charge of a criminal offence and the charge is subsequently withdrawn or the qualified adult is acquitted of the offence
- increase for a qualified child is not payable where the child is detained in a mental hospital
Where a payment is due to a person who is in prison or legal custody, the payment may be made to a person appointed by the Minister to receive it on behalf of the claimant or payment may be suspended until the claimant's release. If the latter, the provision regarding payment having to be obtained within 6 months of the date due will not apply.
A claim to Injury Benefit should be made within 21 days of the accident or of the development of the prescribed disease. See separate guidelines " Late Claims for Injury Benefit" and " Claims and Late Claims".
Injury Benefit is payable at the same rate as full-rate Illness Benefit. It is composed of a personal rate, and where appropriate increases for a Qualified Adult and Qualified child/ren. (see separate " Dependants" guideline re those who qualify for these increases)
The current rates are published in the Information Booklet SW 19.
Payments to Persons in Receipt of certain Social Welfare Payments
Injury Benefit is not payable if a customer is also getting any of the following payments at the full rate:
- Widow's /Widower's and Surviving Civil Partners Pensions, which includes Occupational Widow's/Widower's Pension
- One-Parent Family Payment, which includes Deserted Wives Benefit, Deserted Wives Allowance and Prisoner's Wives Allowance
However, if a customer is getting a reduced rate of any of the above payments they may also get a reduced rate of Injury Benefit, so that the combined amount of both payments is not greater than the rate of Injury Benefit to which they are entitled.
This change does not affect the customer's entitlement to claim Credited Contributions, to maintain the continuity of their PRSI record, while they are unable to work due to illness.
Note: A person who qualifies for Injury Benefit but who is in receipt of a State Pension (Transition)* or State Pension (Contributory) from the Department cannot be paid both. In such a case the person would have the choice of being paid whichever payment is more beneficial to them. Such a claimant can, however, receive Disablement Benefit and Medical Care.
* (State Pension (Transition) is no longer paid where a person reaches 65 on or after 01 January 2014)
Persons under the age of 16 are insured at PRSI Class M. In such cases Injury Benefit is payable at the full rate if the employment amounted to full time employment, otherwise a reduced rate is payable, fixed annually by Regulation.
From 27 September 2007 a person who is claiming a Social Welfare Payment, (other than Carer's Allowance or Carer's Benefit) or who is being claimed for as a Qualified Adult and who is providing full time care to another person may now apply for Carer's Allowance and retain their current payment in full. If they satisfy the conditions for Carer's Allowance it will be awarded at 50% of the personal rate they would qualify for if they were not in receipt of any other payment. See Carer's Allowance guidelines for more information.
Medical Care - see separate Guideline " Medical care".
Disablement Benefit - See Guideline Occupational Injuries - Disablement Benefit
Death Benefit - See Guideline Occupational Injuries - Death Benefits
PART 2: CLAIMS, INVESTIGATION AND DECISION PROCEDURES
Applications for Injury Benefit are made on form MC1, stocks of which are held by doctors, and should be made within 21 days of becoming incapacitated for work. This form as well as being an application also contains a section for the doctor's certificate.
The claim form should be submitted to:
Department of Social Protection
PO Box 1650
Applications may also be sent to Social Welfare Local Offices.
A claim made after the 21 day period can be accepted if good cause can be shown for not claiming in time. However, payment cannot normally be made in respect of any period more than six months before the actual date of making the claim. In certain limited circumstances backdating beyond six months may be considered. See separate Guideline " Claims and Late Claims".
Interim payment of Illness Benefit
When the claim is received in the Department it is, following registration, initially considered for Illness Benefit if it cannot be approved for Injury Benefit. If the contribution conditions for this benefit are met on the insured person's insurance record, it is put into payment on an interim basis pending investigation of the claim to Injury Benefit. The rates of payment for Illness Benefit are the same as those for Injury Benefit, except for cases where reduced rate Illness Benefit is payable.
Investigation of the injury/accident
Injury Benefit entitlement is examined in the light of the employer's confirmation on the claim form, MC1, concerning the accident and the employment. If the employer confirms to the satisfaction of the Deciding Officer that the accident happened in the course of and arising from employment which is insurable at one of the required PRSI rates, the claim is approved by the Deciding Officer.
If the employer does not confirm on the MC1 form that the accident occurred, a form OB4, is issued to them asking for confirmation. When this is returned with the confirmation, the claim is approved as above. Claims where the accident is disputed are sent to a Social Welfare Inspector for investigation.
In cases where the injury is to the back, an additional form, OB137A, may be issued to the insured person if considered necessary by the Deciding Officer. This form asks detailed questions as to what the person was doing at the time of the accident. If the reply is considered to be satisfactory by the Deciding Officer and if confirmation of the accident has also been received from the employer, the claim is approved as appropriate.
Accidents while travelling to or from work
In the case of accidents while travelling to or from work form OB4a and 137c are issued before a decision is made on the claim to Injury benefit. The OB4a asks the employer for more details in relation to the employee's employment on the date of the accident. On return of these forms, the claim is considered in the normal way and the decision is made.
Every employer is required under Social Welfare legislation to take reasonable steps to investigate the circumstances of every accident of which notice is given to him. However, cases arise where the employer does not accept that the accident happened. In such cases the procedure is to refer the claim to the Department's outdoor staff for investigation. This usually entails the Investigator interviewing both the employer and the insured person and getting their respective versions of the accident. Witnesses to the accident might also be interviewed. A report on the case is then submitted to the Injury Benefit Section in which the Investigator may also give their views as to the veracity of the statements obtained. The Deciding Officer then considers all the evidence in the report and decides the claim accordingly.
Investigation of insurability
As the Occupational Injuries Scheme does not cover self-employed persons, cases sometimes arise where the person's employment may not be insurable for Injury Benefit, for example, employment by a relative. Such cases are referred to the Department's Scope Section to see whether the employment is insurable for Occupational Injuries purposes. If the employment is insurable for such purposes, the claim is processed in the normal way. If not insurable, the claim is disallowed.
Investigation of Occupational disease claims
In the case of claims where the incapacity may be due to a prescribed occupational disease, more details are requested from both the employer and the claimant concerning the type of work done and the types of substances contacted during the course of the employment. When a reply is received, such cases are referred to the Department's Medical Assessor before a decision is made.
Claims for Injury Benefit are decided by Deciding Officers in the Benefits Branch.
If Illness Benefit is already being paid to a person, and it is decided that Injury Benefit is payable with effect from the initial date of incapacity, any arrears of Injury Benefit due are issued if a reduced rate Illness Benefit was paid.
The person is advised of the right of appeal to the Chief Appeals Officer where a claim is disallowed.
Part 3: PROCEDURES FOLLOWING AWARD
How Payment Is Made
Claimants to Injury Benefit are informed of the approval of their claim and payment is made weekly. The preferred payment option is by Electronic Fund Transfer (EFT) directly into a Bank or Building Society account. Payment can also be made by cheque or in cash at a Post Office.
Payment in respect of Injury Benefit to a person under the age of 16 years is made to a parent or guardian of such claimants, or to a person appointed by the Minister to receive such payment.
Payments to Nominated Persons
Under the rules of certain occupational sick pay schemes, employees can continue to receive full pay from their employer while on sick leave, but are obliged to remit any social welfare benefits to the employer. Under Social Welfare Regulations, employees may nominate to have their Injury Benefit paid directly to the employer, where they choose to do so. However, the employee may withdraw such a nomination at any time, in which case the Injury Benefit will be paid directly to the employee.
First date of payment.
Normally, payment of Injury Benefit is made from the seventh day of incapacity.
The day of the accident may be regarded as the first day of incapacity. This may also apply in the case of nightworkers.
How Long Payment Lasts
Injury Benefit is payable up to 26 weeks if the incapacity lasts that long. This is known as the Injury Benefit Period.
Subsequent medical certificates should be submitted on a weekly basis for as long as the insured person is incapable of work.
If the person is still incapable of work after 26 weeks, they may have an entitlement to Illness Benefit and/or Disablement Benefit. A letter to this effect is issued to them.
A person in receipt of Injury Benefit may be referred for examination by one of the Department's Medical Assessors to enquire on their incapacity for work.
Incapacities are coded A, B, C or D on the computer system depending on the level of incapacity. Code A would refer to minor incapacities and Code D would refer to the most serious. Accordingly, as weekly certs are keyed in, the computer system selects the cases which are due for referral to a Medical Assessor. The incapacity code on the claim determines the cases for selection. (See separate guideline re "Medical Assessment").
A Deciding Officer may also, if they think that there may be a particular reason for doing so, refer a case to a Medical Assessor.
Assessment of Damages in Civil Cases
From 1st August 2014, the Recovery of Certain Benefits and Assistance (RBA) Scheme enables the Department to recover the value of certain illness-related social welfare payments as a consequence of personal injuries claims. They are recovered from the compensator and not from the injured person. Please refer to Recovery of Benefits and Assistance.