145Cost of an individual claim

#### 145 Cost of an individual claim 145 Cost of an individual claim > > (1) For the purposes of paragraphs (a) and (d) of the definition of cost of claims in clause 143(1), the cost of an individual claim is (except as provided by subclause (2)) the sum of the following— > > > > > (a) the payments, if any, made by the insurer in respect of the claim pursuant to the 1987 Act or the former Act, > > > > > (b) the payments, if any, of damages at common law and under the [Compensation to Relatives Act 1897](/view/html/inforce/current/act-1897-031) made by the insurer either in satisfaction of judgments relating to the claim or in settlement of the claim, > > > > > (c) fees and expenses, if any, paid by the insurer to medical practitioners, investigators or assessors in respect of the investigation of the claim, > > > > > (d) legal costs, if any, paid by the insurer in relation to the settlement or investigation of the claim or as a consequence of proceedings at law, including any such costs that were paid to the claimant or incurred by the insurer on the insurer’s own account, > > > > > (e) the most accurate estimation for the time being of the insurer’s outstanding liability reasonably likely to arise out of the claim, > > > > whether the payments were made or the fees, expenses or costs were paid (or the estimation relates to liability that will arise) during or after the injury year or period of insurance in which the injury to which the claim relates was received (or is deemed by the 1987 Act or the former Act to have been received). > > > (2) However, the cost of an individual claim— > > > > > (a) does not include any amount calculated by reference to the insurer’s costs of administration or profit, and > > > > > (b) in relation to a policy (other than a retro-paid loss premium policy)—is to be reduced by the amounts, if any, that have been recovered or are recoverable by the insurer from any source, other than an amount recovered or recoverable under section 160 of the 1987 Act, from the Insurers’ Contribution Fund or pursuant to a policy of reinsurance, and > > > > > (c) in relation to a retro-paid loss premium policy—is to be reduced by the amounts, if any, that have been recovered or that, in the opinion of the Nominal Insurer, are recoverable by the insurer from any source, other than an amount recovered or recoverable under section 160 of the 1987 Act, from the Insurers’ Contribution Fund or pursuant to a policy of reinsurance, and > > > > > (d) is to be reduced by— > > > > > > > (i) in the case where the injured worker’s weekly payment of compensation is less than $500 or is not known (for example, the claim is for payment of medical expenses compensation only)—$500 or, if the cost of the claim is less than $500, that lesser cost, or > > > > > > > (ii) in any other case—an amount that is the lesser of the following— > > > > > > > > > (A) the amount that the injured worker is entitled to receive as one week’s weekly payment of compensation, > > > > > > > > > (B) if the claim is covered by a policy of insurance that was issued or renewed so as to take effect before 4 pm on 30 June 2006—$1,449.50, > > > > > > > > > (C) if the claim is covered by a policy of insurance that was issued or renewed so as to take effect on or after 4 pm on 30 June 2006, the amount specified by the relevant insurance premiums order that applies to that policy, and > > > > > (e) does not include any amount paid or payable under section 64A (Compensation for cost of interpreter services) of the 1987 Act, and > > > > > (f) does not include any amount which section 54(4)(b) of the 1998 Act (Second-injury scheme) requires to be excluded from the claims experience of the employer, and > > > > > (g) is to be reduced by an amount that is the most accurate estimation for the time being by the insurer of the amount of any input tax credit or decreasing adjustment that may be claimed or has been claimed by the insurer in respect of the payments, fees, expenses or costs included in the cost of the individual claim under subclause (1), pursuant to the [A New Tax System (Goods and Services Tax) Act 1999](http://www.legislation.gov.au/) of the Commonwealth. > > > (3) In this clause, references to the insurer’s outstanding liability reasonably likely to arise out of the claim are references to the amount calculated to be sufficient to meet all reasonably likely future payments in respect of the claim, including adjustments (at such rates, if any, as the Authority from time to time determines) to take account of expected future earnings on investments and expected future inflation or deflation on that amount. > > > (4) For the purpose of this clause, in the case of a claim in respect of the death of or injury to a person caused by or arising out of a motor accident as defined in the [Motor Accidents Act 1988](/view/html/inforce/current/act-1988-102)— > > > > > (a) the insurer’s liability to indemnify an employer in respect of the employer’s liability to the claimant independently of the 1987 Act is taken to be limited to the amount of damages (if any) that would be payable if Division 3 of Part 5 of the 1987 Act applied to the award of damages concerned, and > > > > > (b) the insurer is taken not to be liable for legal costs connected with proceedings under the [Motor Accidents Compensation Act 1999](/view/html/inforce/current/act-1999-041) if damages would not have been payable if that Division applied to that award. > > > (5) If the cost of an individual claim exceeds the large claim limit that applied when the injury to which the claim relates was received (or is deemed by the 1987 Act or the former Act to have been received), the cost of the individual claim is the amount of that large claim limit. > > > (6) For the purposes of subclause (5) in relation to a policy (other than a retro-paid loss premium policy), the large claim limit specified in Column 2 of the Table to this clause applies to an injury that was received or is deemed to have been received during a year specified in Column 1 of that Table in relation to that limit. > > > (7) For the purposes of subclause (5), in relation to a retro-paid loss premium policy, an employer is, before the commencement of the policy, to elect a large claim limit of one of the following amounts to apply to injuries received or deemed to have been received during the period of insurance— > > > > > (a) $350,000, > > > > > (b) $500,000. > > Large claim limits > > | Column 1 | Column 2 | > | Period of 12 months commencing with— | Large claim limit | > | 30 June 1985 | $100,000 | > | 30 June 1986 | $200,000 | > | 30 June 1987 or 30 June of the years 1988 to 1994 | $100,000 | > | 30 June 1995 or 30 June of the years 1996 to 2014 | $150,000 | > | 30 June 2015 | The amount specified in the relevant insurance premiums order that applies to the policy concerned | > | 30 June 2016 | The amount specified in the Workers Compensation Market Practice and Premiums Guidelines that applies to the policy concerned | > | 30 June 2017 or 30 June of any subsequent year | The amount specified by the insurer in the cost of claims in accordance with the Workers Compensation Market Practice and Premiums Guidelines that applies to the policy concerned | > > **cl 145:** Am 2017 (319), Sch 1 \[2\] \[3\].