Income Protection Benefit Guide · 2018-08-30 · 3 Income Protection Benefit uide Your income...

Income Protection Benefit Guide

QSuper Guide

Issued: 23 January 2018


Contents

Your income protection insurance 3How do I apply? 5How is my benefit paid? 6Review and appeal process 7Income Protection Benefit Application form

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Your income protection insurance

This guide explains what you need to do to make a claim for income protection benefits. If you’re a QSuper member with income protection you might be eligible to receive a regular income for up to two or three years (depending on your employment arrangements and date of disablement) if you’re temporarily unable to work due to an illness or injury. If you’ve personalised your cover, you may be entitled to income protection benefits up to five years or to age 65, depending on the cover you’ve chosen. However if you have a Defined Benefit account, your maximum income protection cover is up to two years.

Overview of your income protection coverHere’s a quick reference to your default income protection cover. If you were a member before 1 July 2016 and previously cancelled cover, default cover is not automatically applied.

Default cover from 1 July 2017

I work for Waiting and benefit periods Your benefit

The Queensland Government as a permanent or temporary employee and make standard contributions to my Accumulation account.

(If you’re a Member of the Legislative Assembly, you aren’t eligible for income protection cover.)

Accrued sick leave plus 14 days and payable for up to three years.

If you are aged 16-64 we’ll pay 87.75% of your insured salary (including a Contribution Replacement Benefit of 12.75% of insured salary¹).

Maximum benefit limits apply.

A default employer, or the Queensland Government as a permanent or temporary employee and don’t make standard contributions.

90 days or your accrued sick leave, whichever is greater, and payable for up to three years.

If you are aged 16-64 we’ll pay 87.75% of your insured salary (including a Contribution Replacement Benefit of 12.75% of insured salary¹).


The Queensland Police Service as a police officer.

Accrued sick leave plus approved Queensland Police Service sick leave bank or 180 days, whichever is greater, and payable for up to two years.

If you are aged 16-64 we’ll pay 87.75% of your insured salary (including a Contribution Replacement Benefit of 12.75% of insured salary¹)


A default employer or the Queensland Government as a casual employee, or my account was opened as either:• I have applied for an Accumulation account

direct with QSuper (not through my employer)

• A spouse of a QSuper member, or• A result of a family law splitor• I have an Income account, and an

Accumulation account was opened for me with a contribution (including consolidation from another fund).

You’re not automatically covered with default income protection cover, however you may be able to apply for income protection insurance if you’re eligible.

From 1 July 2016 we’ve got some new insurance arrangements in place to give you even greater peace of mind.

When it comes to determining what terms and conditions your claim will be assessed against, what’s important is not the date you make the claim, but what’s known as the date of disablement. Even if you submit your claim from 1 July 2016, if the date of disablement was on 30 June 2016 or earlier, your claim will be assessed based on the level of cover and the terms and conditions that applied at the date of disablement.

About this guide

1 Insured salary is your salary on which employer contributions are paid to QSuper and for the avoidance of doubt employer contributions do not include salary sacrifice contributions. For the purpose of claims, insured salary will be calculated as at the date of disablement or, if you are gainfully employed on a casual basis, an averaged amount based on the period of 3 months prior to the date of disablement (or over your most recent period of employment, if shorter).


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If you’ve personalised your income protection cover, your waiting period, and/or benefit period and the benefit payable will be as per your approved application. You can find this by logging onto Member Online. (All benefits are subject to benefit cap limits.)

One thing to note - if you’ve previously received an income protection benefit from QSuper and you need to make a claim for the same or a related condition, your maximum benefit period will be reduced by the total number of weeks you received a benefit from all previous claims related to that condition.

What if my date of disablement was before 1 July 2016?If you were a QSuper member before 1 July 2016 and your claim relates to a date of disablement prior to 1 July 2016, your claim will be assessed under the terms and conditions that applied under your previous insurance arrangements.

Cover overview (if membership and date of disablement is prior to 1 July 2016)

I work forWaiting and benefit periods

Your benefit

The Queensland Government or a related entity employer as a permanent or temporary employee and make standard contributions to my Accumulation account. (If you’re a member of the Legislative Assembly you aren’t eligible for income protection cover.)

14 days after you use up all your paid sick leave, and your employer approves sick leave without pay.

Payable for up to 2 years.

We’ll pay 75% of your salary1 for up to two years. We’ll also keep paying your super contributions of 17.75% of your salary.1

A non-Queensland Government or related entity employer and you have income protection cover.

30 days of being totally unable to perform your occupation.

Payable for up to 2 years.

We’ll pay up to 75% of your earned income up to a maximum of $25,000 per month.

Your cover is made up of units with each unit being worth $1,000 per month.

Police officers An income protection benefit is not provided by QSuper

1 The salary used for the purpose of calculating your income protection benefit is your salary for superannuation purposes.

You should also know that if your condition is linked to an illness or injury where the date of disablement was before 1 July 2016 and you start to receive an income protection benefit payment, the maximum benefit period available will be two years and not three.

What about pre-existing conditions and other exclusions?Some of our cover comes with what’s known as a pre-existing exclusion period, which is the period during which we won’t pay an insurance benefit if the illness or injury you’re claiming is related to a pre-existing condition.

If your date of disablement is on or before 30 June 2016, a five year pre-existing exclusion period may apply.

From 1 July 2016, default income protection cover has no pre-existing exclusion period provided you’re At Work on the day cover starts (some exceptions apply).

In all cases, where a pre-existing exclusion period applies and you’re not At Work on the day the pre-existing exclusion period expires, the pre-existing exclusion period will continue to apply until you have been At Work for 30 consecutive days.

There’s more detailed information about pre-existing exclusion periods and other exclusions and how they apply refer to the Accumulation Account Insurance Guide.

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How do I apply?

How do I apply for an income protection benefit?Like most insurance claims, there’s some paperwork you need to complete to apply for QSuper income protection benefit. You need to:

• complete the three parts of the Income Protection Benefit Claim form at the back of this guide

• attach copies of any medical documents you already have on your condition

• provide details on your work history and your income

• complete a Tax File Number Declaration form (you can get this from the ATO, newsagents, your employer, or call us and we’ll send you one). Just remember that if you don’t provide your TFN, your benefit might be taxed at a higher rate.

It’s important you know that you need to cover any costs charged by your doctor to complete the Doctor’s Statement (Part C) of the Income Protection Benefit Claim form.

We’ve tried to make claiming as simple as possible, but please get in touch with us if you need any help completing the form.

When you complete this form, remember to include important information that’s relevant to your claim. If you provide information that’s not accurate or true, we might have to reduce the amount of income protection we pay you, or even stop your benefit and ask you to repay QSuper for any overpayments.

Please send your completed paperwork to us at QSuper, Claims Operations, GPO Box 200, Brisbane Qld 4001.

How do you assess my claim?We work as hard as we can to assess your claim as quickly as possible. Once we receive all the necessary paperwork from you, you’ll be allocated a claims manager and they’ll contact you to talk you through the claims process and answer any questions you might have about your claim.

If we need further medical information from you, we might ask you to provide a medical report about your medical history. We’ll cover costs to get this additional medical information.

If your claim isn’t approved, we’ll send you a statement explaining the reasons for our decision. We explain on page 7 of this guide what you can do if you’re not happy with our decision.

What if I’m working higher duties when I make a claim?We do recognise higher duties, but just bear in mind you need to have been working in the position continuously for at least 12 months to have your benefit calculated at the higher salary if you’re an Accumulation account holder. For Defined Benefit account holders, you need to have been working in the higher-paid position for at least 12 months at the annual review date of 1 July.

Let us know if your situation changesYou must notify QSuper if you:

• return to work or start new employment

• start an approved graduated return to work program

• take any leave other than approved sick leave without pay

• cease to be an Australian Resident

• intend to live outside Australia for greater than 6 months

• earn additional income

• engage in a business or occupation.

To prevent overpayment of your benefit, it’s important that you notify us as soon as possible if any of the above occurs. If there is any overpayment of benefits we will ask you to repay QSuper.

What happens if my condition becomes permanent?If you become permanently disabled your income protection benefit will stop, unless you’ve personalised your income protection cover to a 5 year period or to age 65. Then the income protection cover will continue on that basis.

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Once we approve your claim, payments will be made into your bank, credit union or building society account.

If you have an Accumulation account and salary-based income protection cover, your income protection payments include a contribution replacement benefit (CRB) of 12.75% of your insured salary which is paid to your Accumulation account.

If you have a Defined Benefit account, your super continues to grow while you’re receiving an income protection benefit (in the same way it would if you were working).

Please remember to make other arrangements for any other payments that are automatically taken out of your pay such as private health insurance premiums, child support or voluntary super contributions while you’re on income protection.

If you were a member before 1 July 2016 and your claim relates to an illness or injury which occurred before 1 July 2016 and you were working for the Queensland Government or a related entity, your approved income protection payment will be backdated to the start of your third week of sick leave without pay. Payments will be made weekly and super contributions of 17.75% of your salary will be made while you’re receiving income protection.

If you were a member before 1 July 2016 and your claim relates to an illness or injury which occurred before 1 July 2016 and you’re working for someone other than the Queensland Government or a related entity employer, payments for approved claims will be backdated to the end of the 30-day waiting period. We’ll pay you monthly, in arrears.

Are there any reasons you might stop my income protection benefit?Yes, there are a number of reasons we might stop paying your benefit. If your date of disability occurs after 30 June 2016 the reasons include:

• you no longer meet the definition of total and temporary disablement or partial and temporary disablement

• you turn 65 (or 60 if you’re a police officer)

• you come to the end of your benefit payment period

• you’re determined by the Board to be suffering a total and permanent disablement or to have a terminal illness, unless you have a 5 year or to age 65 benefit period

• if it is determined your condition is a pre-existing condition, and you have a pre-existing exclusion period attached to your cover

• you become engaged in a new business or occupation (unless it is part of an agreed graduated return to work program)

• you stop following the advice of an appropriate medical practitioner

• you choose not to participate, or to continue to participate, in an approved rehabilitation or retraining program

If your claim relates to an illness or injury which occurred before 1 July 2016, reasons we might stop paying your benefit include that you:

• are no longer on approved sick leave without pay

• don’t provide medical information we’ve requested

• don’t attend a medical assessment we’ve arranged

• start working your normal working hours again

• receive WorkCover benefits

• are paid for the maximum two year benefit period

• change your employment status to casual

• stop working for an eligible QSuper employer

• if you are employed by the Queensland Government, you no longer meet the definition of temporary disablement. If you are not employed by the Queensland Government, you no longer meet the definition of Total Disability or Partial Disability.

What do I need to do while I’m receiving an income protection benefit?While we’re paying you an income protection benefit we might ask you to:

• get medical report forms completed on a regular basis by your GP or medical specialist

• get detailed medical reports (from your GP or medical specialist)

• attend independent medical or other assessments by specialists we nominate (your employer might also request this)

• have an interview over the phone or in person with our staff or agent/s

• participate in rehabilitation or return to work programs.

This just helps us work out if you’re still eligible to continue to receive income protection.

How is my benefit paid?

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Review and appeal process

Graduated return to work programAs you recover from your illness or injury, you might ease back into work as part of a graduated return to work program. If this happens, your employer will pay for the hours you work, and we’ll pay a percentage of the difference between your insured salary (or pre-disability income if your cover is in units) and your reduced salary.

So even if you return to work you’ll still receive a partial benefit if you continue to be disabled. For example if you return to work at 40 per cent of your insured salary (or pre-disability income) we will pay you 60 per cent of your income protection benefit.

To help you further, if your claim relates to a date of disablement on or after 1 July 2016, and you return to work for at least 20 per cent of your substantive hours you may be eligible for the graduated return to work additional payment for a period of up to eight weeks. This benefit may increase your total benefit payment. For more details about the calculation refer to the Accumulation Account Insurance Guide. Graduated return to work additional payments will end as soon as:

• you stop participating in an approved graduated return to work program or

• you return, or are able to return to work at your substantive hours or

• the graduated return to work additional payment has been paid for eight weeks.

What if I’m not happy with the decision?We understand not everyone will be happy with the decisions made about their claims and you’re welcome to lodge an appeal for review by QSuper. Send your appeal in writing to: Quality and Compliance, Operations, QSuper, GPO Box 200, Brisbane Qld 4001. Remember, you need to cover any costs to obtain medical reports to support your appeal.

If you’re still not satisfied with the review decision, you can lodge a complaint with the Superannuation Complaints Tribunal. The SCT imposes time limits within which to lodge a complaint with them. Please contact the SCT directly to ascertain your eligibility to lodge a complaint.

Additional info about this guideMake sure you read the Accumulation Account Insurance Guide and this guide before you complete the Income Protection Benefit Claim form that’s attached to the guide. And keep the guide somewhere handy in case you need to refer to it.

To make a claim you need to complete all three parts of the Income Protection Benefit Claim form:

• the member statement (Part A) needs to be completed by you, and make sure you attach all available medical certificates describing your illness or injury and any other relevant medical information along with details of any additional income or earnings from other employment or any business you may be involved in

• the employer’s statement (Part B) needs to be completed by your employer

• the doctor’s statement (Part C) needs to be completed by your medical practitioner or specialist.

It’s important the claim form is completed in full before it’s sent to us or your claim could be delayed.

We can only pay your benefit into your bank, credit union or building society account. This means we can’t pay it into a business or loan account. You should know that if you provide incorrect details, there could be a delay in your payment or a loss of interest, and we can’t accept responsibility for this.

What is the Superannuation Complaints Tribunal (SCT)?The SCT is an independent tribunal set up by the Commonwealth Government to review complaints relating to decisions made by super funds.

But please bear in mind you need to use our internal appeal process before going to the SCT. If you’re not happy with the review decision or we haven’t contacted you within 90 days of lodging your appeal, call the SCT on 1300 884 114. They’ll let you know if they can deal with your complaint and the information you’ll need to provide. You can visit the SCT website at sct.gov.au for further information.

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QSuper Form1

Please complete in block letters, in blue or black ink.

Income Protection Benefit Claim (Part A) – Member StatementWho needs to complete this form?You need to complete this part of the claim form to apply for income protection. We need detailed information about your job and your illness or injury to be able to assess your claim. And please make sure you provide your medical practitioner’s details in case we need to get in touch with them for more information. If you need any help completing this form, please give us a call.

2 Details of your medical condition

Please attach copies of any medical evidence you already have on your illness or injury, and any other relevant information.

What treatment are you currently receiving?

When did you first see a doctor about your illness or injury? (dd/mm/yyyy)

If yes, tell us the date you returned to normal duties. (dd/mm/yyyy)

When was your illness first diagnosed or date you were injured? (dd/mm/yyyy)

When did you first stop working because of your illness? (dd/mm/yyyy)

Client number

Surname

Email address

Are you employed or self-employed in any other role? If yes, please provide details.

Title Given names

Previous name1 (if we know you by another name)

Home phone numberDate of birth (dd/mm/yyyy)

Payroll numberName of your employer

HR/payroll contact number HR/payroll contact name

Mobile phone number

You can find your client number on your annual statement or by logging in to Member Online.

1 Personal details

Postal address

State Postcode

Residential address

State Postcode

As above

Yes No

Have you started a graduated return to work program? If yes, please specify the date this started.

Yes No

Have you returned to normal work duties?

Yes No

Name of your illness or injury (please provide a detailed description)

What was the cause of your illness or injury?

Are you receiving, or are you willing to receive, appropriate medical care that’s recommended by your treating medical practitioners?

Yes No

FrequencyWhen did you start your treatment? (dd/mm/yyyy)

1 If your name has changed and you work for the Queensland Government or related entity employer, let your payroll office know and they’ll then let us know. Otherwise, please send us a certified copy of either a marriage certificate or other legal change of name document.

If yes, please make sure you provide us with a copy of the discharge summary from the hospital.

Have you been hospitalised for this condition?

Yes No

Please tell us your capacity to do the following activities: Position/title

Lift (floor to waist)

Lift (knee to shoulder)

Lift (waist to overhead)

Push/pull

Carry

If no, please describe the help you need and how you’re limited.

Can you dress yourself? (e.g. putting on and taking off clothes)

Yes No

Please describe the help you need and how you’re limited.

Can you bathe yourself? (e.g. washing and showering)

Yes No


Can you use the toilet by yourself, including getting on and off?

Yes No


Are you mobile? (e.g. walking, getting in and out of a chair or bed)

Yes No

Please provide your treating doctor’s details below.


Can you feed yourself? (e.g. getting food from a plate to your mouth)

Yes No


Can you do housework? (e.g. cooking and cleaning)

Yes No

Are you able to drive?

Yes No

Do you take care of children or other dependants?

Yes No

Does your condition affect your ability to do these activities?

Yes No

3 Your job details and employment history

Please describe your hobbies/interests/social activities.

If no, please provide details.

What duties are/were you able to do?

What duties are/were you prevented from doing?

If yes, please describe how you’re affected.

Please describe your job in detail, including all of your duties and responsibilities (and attach a position description and a copy of your resume if possible).

If your job involves manual handling, please provide details of the types of items you might lift/push/pull/carry, the physical demand of these tasks and how often you do these tasks.

What educational qualifications, degrees and/or certificates (including first aid and OHS) do you hold? Please include the year you achieved these when providing details below.

Secondary school (e.g. year 10, year 12)Tertiary (university or technical college)

Post-graduate

TAFE

Other

2

Income Protection Benefit Claim (Part A) – Member Statement

Email address

Name

Phone number

3


What specific work skills do you have (for example, management/supervision, retail, computer skills)?

Please give details of previous employment (approximate dates are fine).

Employer

Employer

Position/title

Position

End date (dd/mm/yyyy)

End date (dd/mm/yyyy)

Start date (dd/mm/yyyy)

Start date (dd/mm/yyyy)

Please describe all your duties and responsibilities.

Please describe all your duties and responsibilities.

If you’ve received an income from any of the sources we list below, please let us know the income, how often you receive it, the date payment started and any lump sum payments below.

Employer or business

1 Weekly, fortnightly, or monthly

Workers’ compensation

Department of Human Services

Pension Scheme

Frequency1

Date payment started (dd/mm/yyyy)

Another insurance policy

Income amount (gross)

WorkCover claim numberWorkCover case manager’s phone number

End date (dd/mm/yyyy)Start date (dd/mm/yyyy)

WorkCover case manager’s name

4 Other entitlements

Please tell us the start and end dates of the WorkCover claim period.

If you’re claiming WorkCover, please tell us your:

Have you claimed, or do you plan to claim, a benefit from WorkCover for this illness or injury?

Yes No

$

Frequency1



$Date payments stopped(dd/mm/yyyy)

Date paid (dd/mm/yyyy)Lump sum benefits

$

Frequency1





$

Frequency1





$

Frequency1





$

Frequency1





$

Date payments stopped(dd/mm/yyyy)


$


$

Other (please specify)

Provide details of other sources of income which may include: motor accident compensation, Social Security, Statutory or other government payments.

4


Please provide details of your packaged salary below. (including base salary, fees, and regular bonuses, allowances, overtime earnings and commissions)

5 Details of earnings before your illness or injury (complete this section if you don’t work for the Queensland Government)

What were your income and expenses for the last 12 months (pre-disability)?

What were your income and expenses for the last 24 months (pre-disability)?

Gross income from occupation

Expenses

Expenses

Expenses



What was your base salary (gross) prior to your illness or injury?

What was your income (gross) prior to your illness or injury? $

$

$

$

$

$

$

$

What income did your business earn in the last 12 months, as a direct result of your physical exertion or activity through usual occupation?

6 Please complete if you’re self-employed

We can only make payments into an Australian bank, credit union or building society account that’s in your name or a joint name This means we can’t make payments into a business, trust or loan account.

You should know that if you provide incorrect details, there could be a delay in your payment or a loss of interest, and we can’t accept responsibility for this.

Name of bank, credit union or building society

Account numberBranch (BSB) number

Account name

7 Receiving your payment

Signature

Date (dd/mm/yyyy)

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1 If you’re signing as a power of attorney and you haven’t already given us a certified copy of your power of attorney documentation, please attach it to this form. 2 QSuper’s insurers include TAL Life Limited, QInsure, OnePath and Suncorp.

I agree that the individuals and organisations listed below can have access to my personal and medical information so that they can investigate and assess my claim:

• Workers’ compensation

• CTP insurer

• Federal and State Government agencies including the Department of Human Services and the Department of Veterans’ Affairs

• my employer (only with my written consent)

• my accountant

• my doctors, specialists and their agents

• QSuper

• QSuper’s insurers

• QSuper’s appointed assessor which may be located overseas in North America or the European Union.

• I’m the person named on this form or have power of attorney to act on the member’s behalf.1

• I confirm the information provided in this form is true and correct, and I haven’t withheld any information that’s relevant to my claim.

• I agree to provide all medical information and undertake any medical or occupational assessments requested by QSuper.

• I understand I can’t receive an income protection benefit from QSuper and compensation from WorkCover for the same period.

• I understand that if I am granted compensation from WorkCover for the same period, I may be asked to pay back QSuper the income protection benefits paid to me during that time.

• I authorise any insurer (including workers’ compensation/CTP insurer), government agencies (including the Department of Human Services and the Department of Veterans’ Affairs), my employer, accountant or other relevant holder of information to release to QSuper or its insurers2 information they might need to assess my claim.

• I understand that a photocopy of my authority is considered as valid as the original.

• I authorise QSuper to refer to any statements that have been made in connection with my application for insurance and any medical reports to other entities involved in providing or administering my insurance (for example reinsurers, third party administration or specialist claims providers and legal advisers) or persons appointed to obtain financial, employment or medical related information in support of the assessment of my claims from any other entity holding information on me.

• I consent to any sensitive information such as medical information collected in this form being used by the QSuper Board and its insurers1 and any of its authorised service providers for the purposes of assessing my eligibility for personalised cover and for the assessment or investigation of any future claims made in relation to such cover.

• I have read QSuper’s Your Privacy factsheet and I understand how QSuper will collect, use and disclose my personal information to relevant to this claim.

Signature

Name

Date (dd/mm/yyyy)

Name

If we need to contact you about this form, tell us which way you’d prefer to be contacted?

Mobile Home phone Email

8 Declaration and authorisation


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Where do I send the form?Once you’ve completed the form and attached any necessary documents, send it to us at QSuper, Insurance Operations, GPO Box 200, Brisbane Qld 4001.

Make sure you use this checklist to check you’ve completed the claim form and you have all the supporting documents ready to send us.

Checklist

I’ve provided all the relevant information in section 1.

I’ve provided details on my condition in section 2 and attached copies of any medical evidence I already have on my condition (and any other relevant information).

I’ve completed my job details and employment history in section 3 (and section 5 for non-Queensland Government employees).

If I’m claiming any other entitlements, I’ve provided details in section 4.

I’ve signed the QSuper declaration in section 7.

I’ve provided details of my bank account in section 7 and have attached a copy of my bank, credit union or building society statement.

I’ve provided a completed Tax File Number Declaration form.

The information you’ve provided will be used to assess your benefit entitlement for insurance. You should keep a copy of your completed form and this guide as you may want to refer to it in the future.

This form and all products are issued by the QSuper Board (ABN 32 125 059 006 AFSL 489650) as trustee for QSuper (ABN 60 905 115 063). We take the privacy of your personal information very seriously. We’re collecting personal information from you so we are able to assess your claim and are authorised to do this under the Superannuation (State Public Sector) Act 1990. We may also collect information from your employer, government agencies, other superannuation funds, anyone you authorise and if it is required or authorised by law. We may disclose your information to your employer, authorised service providers (including QInsure Limited ABN 79 607 345 853 AFSL 483057 and any of its authorised service providers), other superannuation funds and government agencies and to third parties if we need to, if you’ve given consent to the disclosure, or if we’re required to by law. If you want to know more you can download QSuper’s Your Privacy factsheet from our website or call us on 1300 360 750 and request a copy. The information outlined in this form is general information only and doesn’t take into account your personal objectives, financial situation, or needs. Before you make any decision regarding a QSuper product you should consider the PDS, which you can download at qsuper.qld.gov.au, or call us on 1300 360 750 for a copy. © QSuper Board 2018

Member Centres 70 Eagle Street Brisbane and 63 George Street BrisbaneTelephone 1300 360 750 (+617 3239 1004 if overseas)Monday to Thursday 8:30am to 5:00pm AEST Friday 9:00am to 5:00pm AEST

Postal address GPO Box 200 Brisbane Qld 4001Fax 1300 242 070Website qsuper.qld.gov.au

ABN 60 905 115 063SFN 261041941CNC-1135 01/18 IB29

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Income Protection Benefit Claim (Part B) – Employer’s StatementWho needs to complete this form?This section of the claim form needs to be completed by your employer (HR or payroll office staff). Please ensure all questions are answered before you send it to us.

2 Salary information

What was your employee’s full time salary at 1 July before they went on sick leave without pay (SLWOP)?

Salary: When you provide your employee’s salary, it needs to be their remunerated salary upon which the superannuation contribution is calculated.

If your employee works part-time, please provide us with their full-time salary and indicate the part-time ratio in section 3.

What was the employer paid Superannuation Guarantee Contribution (SGC) rate for your employee?

What was your employee’s full time salary prior to starting sick leave?

Surname

Name/s

Title Given names

Payroll numberDate of birth (dd/mm/yyyy)

Phone numberPosition/Job Title

Position/job title

Place of employment and region

1 Employee information 3 Employment information

Employer rehabilitation contact name

When did your employee last attend work? (dd/mm/yyyy)

When did they start sick leave? (dd/mm/yyyy)

What date was all accrued sick leave exhausted? (dd/mm/yyyy)

Phone number

Email address

Email address

Preferred method of contact?

Email Phone

Is your employee paying child support?

Yes No

QSuper Form1

%

Does your employee work:

Full time

Part-time p/t fortnightly ratio

Casual

Contractor contract end date (dd/mm/yyyy)

Has your employee received other paid leave since all accrued sick leave was exhausted?

Who else, apart from employer rehabilitation contact above, should be advised upon assessment of claim?

Yes No

If yes, what date does this cease?

1 July 20

Date (dd/mm/yyyy)

$Salary

per fortnight

Date (dd/mm/yyyy)

$Salary

per fortnight

2

Income Protection Benefit Claim (Part B) – Employer’s Statement

As the employer, you need to complete this employer’s statement for any employee who is covered by QSuper’s income protection insurance.

Please ensure you complete all the sections in the employer’s statement before returning to QSuper promptly.

This will assist QSuper to progress the assessment of your employee’s claim for an income protection benefit.

If your employee’s situation changes, it is important you let us know straight away. This includes changing the type of leave they take, if they start working again, or their employment is terminated. Please call us on 1300 360 750 or email us at [email protected] to let us know.

Where to send the completed form?Once you have completed this form you can: Email us at [email protected]

Additional information about this form 4 Additional comments

5 Employer information

Please supply any information that clarifies or supports this Employer’s Statement.

Name of employer

Position held

Email address (not generic email address)

Full name of authorised officer

Phone number

Date completed (dd/mm/yyyy)




ABN 60 905 115 063SFN 261041941CNC-1135 01/18 IB29

QSuper Form1

Income Protection Benefit Claim (Part C) – Doctor’s StatementWho needs to complete this form?Your doctor needs to complete this part of the claim form. We need detailed information from them about your illness or injury before we can pay you an income protection benefit. Remember you need to cover any costs your doctor charges to complete this form. Also be sure to check out the Additional info about this form on page 5 to make sure you have all the info you need.

Please complete in block letters, in blue or black ink.

Surname

Title Given names

Date of birth (dd/mm/yyyy) Weight (kg)Height (cm)

1 Claimant’s details (your patient)

2 Treating medical practitioner (completing this form)

Name

Email address

Phone number

Specialty Practice

Postal address

State Postcode

Are you this patient’s usual general practitioner?

Yes No

If yes, what date did you first begin treating this patient? (dd/mm/yyyy)

If yes, please provide the contact details of the doctor they first saw and the consultation date.Name

Did this patient see any other doctors before they first consulted you?

Yes No

Specialty

Date of consultation (dd/mm/yyyy)

Who diagnosed the patient’s condition?

Based on your objective clinical findings, please confirm the patient’s diagnosis.

Please describe your objective findings that support the diagnosis (for example, if the diagnosis relates to a mental illness, please provide criteria as per DSMIV)

If the diagnosis relates to a musculoskeletal condition, please provide any details on ROM, strength testing, neurological testing and any other special tests.

If your objective findings have changed since the initial diagnosis, please tell us any updated findings.

If the diagnosis relates to a cardiac condition, please indicate the patient’s cardiac functional capacity:

Class 1 – No limitations

Class 2 – Slight limitations

Class 3 – Marked limitations

Class 4 – Severe limitations

2

Income Protection Benefit Claim (Part C) – Doctor’s Statement

3 Medical History

Please outline the patient’s initial symptoms relating to this condition.

If yes, please describe how.

If yes, from when? (dd/mm/yyyy)

When did the patient’s symptoms for this condition first start or occur? (dd/mm/yyyy)

Have the patient’s symptoms changed in frequency or severity?

Yes No

Has the patient ever experienced these symptoms, or similar symptoms, previously?

Yes No

If yes, please provide details.

4 Treatment and progress of the illness or injury

What active treatment (such as physiotherapy, surgery, counselling, medication) has the patient received from you and other practitioners since their illness or injury was diagnosed?

Nature of treatment

Date referred

Frequency of treatment

Effectiveness of treatment

Medication

Dosage/frequency

Date prescribed

Effectiveness of medication

Is there any additional treatment that would help improve the patient’s functional capacity that they mightn’t be able to access due to a lack of financial resources or other reasons?

Yes No

If yes, please provide details.

What tests or investigations have been done to date and what were the results of these tests?

Please attach copies of test results where applicable (e.g. MRI, CT scan, x-ray, ultrasound, blood/urine tests, ECG)

3


Has your patient been referred to any consultants or specialists?

Yes No

If yes, please provide the consultant/specialist’s contact details.

Name

Practice

Date of first appointment (dd/mm/yyyy)

How often are you seeing the patient at this time? When is their next appointment?

Phone number

Do you believe the patient has reached maximum medical improvement (MMI)?

Yes No

If yes, please explain below.

5 Your patient’s capacity to work

What is your understanding of the patient’s occupation and their duties?

Is the patient currently working?

Yes, part-time Yes, full-time No

If yes, how many hours are they working per week?

If no, how do the symptoms of their illness or injury stop them from working?

Please outline any specific medically supported restrictions and/or limitations that would need to be considered to help the patient return to work.

If temporary, what’s the expected timeframe of the restrictions and/or limitations?

Restriction and/or limitation 1

Functional capacity impacted e.g. lifting, sitting

Restriction and/or limitation

Current capacity e.g. 30kg, 30 minutes

Are these considered permanent?

Temporary Permanent







Temporary Permanent

From what date was your patient unable to work due to the injury or illness? (dd/mm/yyyy)

Postal address

State Postcode

4


Are there any specific or temporary workplace changes that could help the patient return to work? Please outline below.

Are there any medical barriers to the patient returning to work within the restrictions/limitations outlined above?

If the patient isn’t responding to treatment or there are delays in accessing treatment, would you appreciate input from an independent medical specialist?

If yes, please provide details below.

Yes No

Yes No



















Temporary

Temporary

TemporaryPermanent

Permanent

Permanent

5


6 Declaration

The information I’ve provided in this form is true and correct at the time of completion.

Signature

Name

Date (dd/mm/yyyy)

Where do I send the form?Once you’ve completed the form and attached any necessary documents, send it to us at QSuper, Insurance Operations, GPO Box 200, Brisbane Qld 4001.

Make sure you complete your section of the claim form in full so the patient’s claim isn’t delayed.

If you’d like to know more about our privacy policy, download QSuper’s Your Privacy factsheet on our website at qsuper.qld.gov.au

Additional info about this form




ABN 60 905 115 063SFN 261041941CNC-1135 01/18 IB29

This guide and all products are issued by the QSuper Board (ABN 32 125 059 006 AFSL 489650) as trustee for QSuper (ABN 60 905 115 063). The information provided is general information only and doesn’t take into account your personal objectives, financial situation, or needs. You should consider whether the product is appropriate for you by reading the product disclosure statement (PDS) and consider seeking financial advice before making a decision. You can get a copy of the PDS by downloading a copy from our website at qsuper.qld.gov.au or call us on 1300 360 750. © QSuper Board 2018



ABN: 60 905 115 063 SFN: 2610 419 41CNC-1135 01/18 IB29

Income Protection Benefit Guide · 2018-08-30 · 3 Income Protection Benefit uide Your income...

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