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What are my options if a workers’ compensation claim is rejected?

Workers’ compensation offers invaluable financial support for those who are injured or become ill during the course of their employment.

When everything runs smoothly, claimants receive the money they need for various expenses to cover day-to-day costs and rehabilitation efforts, if necessary. For serious injuries or illnesses, insurers may even pay out a lump sum for permanent impairment.

Unfortunately, not everyone’s compensation claim is approved, and eligible people are often rejected, potentially for spurious reasons. Let’s take a look at why your claim may get turned down, as well as examine what steps you should take next.

What happens at the end of a workers compensation case

At the end of your workers compensation case, WorkCover decides whether to approve or deny your claim. Your approval or denial will come in the form of a decision letter.

If you are getting provisional payments for a physical or psychological injury, you may be able to still keep receiving them while you lodge your application to dispute the rejection.The process for lodging a dispute varies by state and territory. You are entitled to hire your own legal representation for the dispute process.

You may also have other avenues if your injury has resulted in permanent impairment. By definition, a permanent impairment would prevent you from working at the job you had before, and possibly any other job. Temporary impairment has an expected end date, as it can be assumed that the injury is treatable and will eventually resolve.

What happens when an employee appeals against a workers’ compensation decision?

If your workers compensation claim is rejected, you can lodge an appeal or dispute for compensation and medical benefits.

How does the appeals process work?

You typically have six months to file a WorkCover claim. How long it takes to be addressed can be anywhere from a few weeks to a few months, depending on the facts of your physical or mental injury claim. If your workplace injury claim is rejected, you can open a dispute. You’ll likely be approved for provisional payments if your compensation claim for a work injury is fairly straightforward and you are unable to work. This weekly compensation may be extended later.

Victoria

What should you do if you have a WorkCover claim rejected in Victoria? The procedure is for the Accident Compensation Conciliation Service (ACCS) to help resolve workers compensation disputes between workers and employers or VWA Agents / Self Insurers. Conciliation uses the principles of Alternative Dispute Resolution, and is required before a case can be taken to the Court.

Why are WorkCover claims rejected in Victoria?

Workers compensation claims are often denied without a clear reason. However, some of the most common causes for a rejection are due to pushback from your employer or insurance company, who may try to claim you can’t file because of your specific employment status or what you were doing at the time of the injury. They may even argue it isn’t valid because you don’t have witnesses. Alternatively, they may say your pain is caused by a pre-existing injury and demand a medical certificate.

What should you do if your WorkCover claim has been rejected?

To open a dispute, you must provide a copy of the decision letter you received from the VWA Agent. If you never received a response from the VWA Agent about your entitlements, you can lodge a Request for Conciliation along with any copies of correspondence sent and received from the VWA Agent or Self Insurer.

You’re required to lodge a Request for Conciliation Form within 60 days of receiving the decision you wish to dispute. In some cases this requirement may be waived based on the circumstances, for example if you were for some reason unable to make the claim within 60 days.

You’ll need to personally sign the request form, and include the details of the dispute as well as the letter itself (if available), the “reasons for decision” attached to the letter; and “all documents in your possession, custody or power” as long as you don’t claim privilege or immunity.

During the Conciliation conference, the VWA Agent or Self Insurer may withdraw or alter their original decision. In this case, you may be able to reach a speedy agreement. Alternatively, the Conciliation Officer or any party involved may propose a recommendation for resolving the dispute and see if all parties can agree.

If no agreement is reached, the Conciliation Officer may exercise discretion to refer the matter to the Medical Panel. This only happens if medical facts are not in dispute, and the Medical Panel will provide a final and conclusive opinion.

When a Conciliation Officer is satisfied that there is “no arguable case” for denying payment, they may give a Direction for payment of medical expenses and or a weekly disbursement be made for a limited period to the employee.

If an “arguable case” is deemed to have been made by the VWA Agent or Self Insurer, and the Conciliation Officer can certify the claimant has taken all reasonable steps to settle the dispute, they will issue a Genuine Dispute or Unresolved Certificate, which means you and your attorney can proceed to take the matter to the relevant court with your Outcome Certificate in hand.   

NSW

To lodge a dispute in NSW, you must first submit a claim with the insurer. Details on this process can be found on the State Insurance Regulatory Authority (SIRA) website.You may also need to request an internal review from the employer or insurer before you can lodge a dispute.

Why are WorkCover claims rejected (NSW)?

The workers’ compensation watchdog (SIRA) lists three common reasons why cover providers may turn down a claim. These are:

  • The individual is not considered a ‘worker’;
  • The injury or illness was not deemed sufficiently work related; or
  • The claimed expenses are not reasonable for the injury or illness suffered.

 

A rejected claim can have a significant impact on your financial health, leaving you unable to support yourself and your family at a difficult time.

What should you do if your WorkCover claim has been rejected?

Contacting the insurer to request a review of their decision is your first step. According to SIRA, insurers should send you an application form so you can explain why you feel a review is necessary. Use this opportunity to attach any additional information relevant to your claim. The insurer is required to respond within 14 days, at which point it will either maintain its previous decision or approve your claim. If you are rejected again, you still have options.

Go through the Personal Injury Commission

You can lodge a dispute application through the Personal Injury Commission’s online portal. If you are legally represented, your attorney will lodge the application on your behalf.

When doing so, your application must be accompanied by all of the relevant information you intend to rely on. You may not be allowed to provide more information later in the dispute resolution process, so make sure you double check everything with the help of your lawyer.

After the Commission has received the application and information, it will assign the dispute to the most appropriate dispute resolution pathway in the Workers Compensation Division. This can be one of four pathways:

  • Legal disputes
  • Medical disputes
  • Damages disputes
  • Expedited disputes

The Commission decides which is the most appropriate pathway, but reserves the right to change the pathway for a dispute at any time.

Why are WorkCover compensation claims rejected?

Most employees who are injured at work eventually make a WorkCover claim. You can make  a workers compensation claim for a mental injury, a physical injury or both. Initially, WorkCover is responsible for deciding your claim. If it rejects your claim, you have the right to dispute the action.

Common reasons for having your WorkCover claim rejected in NSW are because you didn’t supply evidence of your injury, or your employer or insurer objected to the claim and provided a more compelling argument. You may also have failed to follow the proper steps for filing your claim in the wrong jurisdiction.

Your employer may try to have your workers compensation claim rejected by saying you aren’t qualified to make a claim or that no one else saw you get injured. These are not automatic grounds for having your claim denied. Your attorney can help you achieve your goals and obtain your rightful compensation for your injury.

What should you do if your WorkCover compensation claim has been rejected?

If you’ve had a WorkCover claim rejected, Victoria and NSW both give you 60 days to dispute. If you’ve incurred a large amount of medical expenses (more than $682), you have a Major Claim. If the amount is less than $682, it is a Minor Claim. 

A workcover claim can be reopened in Victoria if you have new symptoms that are caused by your original injury. You may qualify for more compensation for medical treatment for your injury if it has worsened.  

Contacting a specialist workers’ compensation lawyer 

At any point during a claim or claim dispute, you can enlist the services of an experienced lawyer to assist your case.

The workers’ compensation system can be complex, which is why it helps to have someone who is able to guide you through every step of the process.

If you’ve had a workers’ compensation claim rejected, or would simply like advice on how to pursue benefits while injured or ill, please contact us for no-obligation legal advice about your claim today.

© 2021 
Gerard Malouf & Partners
 — Personal Injury Compensation Lawyers

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