Sch 1Defined benefits—dispute

Schedule 1 Defined benefits—dispute resolution (see s 186 and s 192) item 1 59 (2) refuse late application because applicant does not have full and satisfactory explanation 2 62 refuse to pay applicant’s expenses because not allowable expenses under MAI guidelines 3 65 (1) reject liability for defined benefits 4 65 (1) reject liability for defined benefits because applicant not a person mentioned in s 55 (1) 5 65 (1) reject liability for defined benefits because application made on behalf of applicant by someone other than a person mentioned in s 55 (2) 6 66 (1) not pay income replacement benefits because applicant not entitled to those benefits under s 89 7 66 (1) not pay treatment and care benefits for expenses incurred for stated treatment and care because of 1 or more of the (a) treatment and care not reasonable and necessary; (b) treatment and care did not relate to personal injury sustained in motor accident; (c) injured person has not paid for the treatment and care and is not liable to pay for the treatment and care

item 8 66 (1) not pay treatment and care benefits for domestic services expenses incurred by injured person in employing someone to provide domestic services to injured person’s dependants because of 1 or more of the following reasons: (a) expenses not reasonable and necessary; (b) injured person did not provide those services to dependants before the motor accident; (c) dependants are able to undertake those services 9 66 (1) not pay treatment and care benefits for travel expenses incurred by injured person and a parent or other carer accompanying injured person because of 1 or both of the (a) expenses for travel and accommodation not reasonable and necessary; (b) travel not undertaken to undergo treatment and care 10 66 (1) not pay funeral benefits because applicant not entitled to funeral expenses under s 178 11 96 decision about amount of income replacement benefits injured person entitled to for first payment period 12 97 decision about amount of income replacement benefits injured person entitled to for second payment period 13 100 (1) decision about injured person’s post-injury earning capacity 14 101 (3) (b) (ii), (4) (b) (ii) or (5) (b) (ii) refuse to make earlier payment of income replacement benefits to injured person who makes late application for defined benefits because not satisfied there are exceptional circumstances justifying earlier payment 15 103 (2) refuse to pay injured person interim weekly payment 16 103 (4) refuse to pay injured person lower interim weekly payment 17 105 (2) suspend injured person’s benefit payments 18 107 (1) (b) reduce or stop paying income replacement benefit payments

Internally reviewable decisions Part 1.1 item 19 121 (1) make reasonable request to injured person to attend health practitioner for assessment of treatment and care needs 20 121 (3) suspend payment of treatment and care benefits and income with reasonable request to attend health practitioner 21 124A (1) suspend payment of treatment and care benefits and income with a recovery plan for the person 22 126 (2) refuse to approve treatment and care not mentioned in injured person’s recovery plan because treatment and care not reasonable and necessary in the circumstances and will not assist with injured person’s recovery or management of person’s injury 23 128 (2) (a) (i) (B) refuse to make earlier payment of treatment and care expenses, domestic services expenses and travel expenses in relation to late application for period starting on date that is 13 weeks before date of application because insurer not satisfied that there are exceptional circumstances justifying earlier payment 24 129 (1) not pay treatment and care expenses, domestic services expenses and travel expenses because of 1 or more of the (a) the expenses cannot be verified; (b) the expenses have not been incurred; (c) the insurer has previously paid the expenses; (d) for treatment and care expenses—the expenses were— (i) not approved by the insurer; or (ii) not set out in the injured person’s recovery plan 25 139 (2) tell applicant for quality of life benefits that insurer believes person’s injuries have stabilised but the person is not likely to have a permanent impairment as a result of the injuries