Having your workers’ compensation claim rejected can be a real blow, especially on top of the stress of managing your injury. But how do you handle this? What do you do next? A rejection doesn’t necessarily mean it’s the end of the line for your claim.
We talk you through what to do if your WorkCover claim has been rejected, and the steps available to you if you want to dispute it.
Reasons why your WorkCover claim may be rejected
There can be many reasons why WorkCover declined your claim. It can be as simple as not submitting the application on time, or not providing enough evidence that your injury was caused by work.
According to WorkSafe Queensland, about 91,000 WorkCover claims are lodged each year in Queensland. About 76 per cent are accepted, while only five per cent are rejected.
When assessing your claim, WorkCover typically look at:
- Whether your claim was made on time
- If you’re a Queensland worker or eligible volunteer
- Whether your injury is work-related including how, where and when it happened
- How long you’re unable to work for
- What your treatment needs are
Remember, WorkCover will only accept claims when it’s clear that your work is a significant contributor of your injury.
Steps to take if your claim is rejected
If your claim is rejected, there are steps you can take. It’s important to read these carefully, paying attention to any strict time frames that apply.
Step 1: Request a review
You first need to find out why your claim was denied. While WorkCover should send you a copy of their reasons, you have 20 days from the date of the decision to request it. If you don’t think the decision is fair, you can request a review with the Workers’ Compensation Regulator.
Part of the Office of Industrial Relations, they are responsible for reviewing insurer decisions according to the Workers’ Compensation and Rehabilitation Act 2003 (the Act). The good news is that as they are an independent authority, and their decisions are not influenced by WorkCover or anyone else.
To lodge a review, you must:
- Fill out the Workers’ Compensation Regulator review application form
- Explain why you think WorkCover’s decision is wrong
- Provide supporting documents such as medical reports and witness statements
- Submit the application within three months of the date of WorkCover’s decision
Data shows that three per cent of rejected decisions are disputed and reviewed, with 60 per cent of reviews confirming the insurer’s original decision. But don’t let this discourage you. Research also shows that review applications increased by 3.5 per cent between 2018-19 and 2019-20.
The Workers’ Compensation Regulator is usually required to make a decision within 25 business days but they are currently experiencing significant delays in processing. There can also be delays if your application is not complete. We recommend confirming with them that they received your application and have everything they need a couple of days after lodging it.
Step 2: Appeal the review decision
Say you submit your review to the Regulator and they uphold the original decision not to accept your claim. Don’t lose hope – you may have another opportunity to change the outcome.
If you disagree with the decision of the Workers’ Compensation Regulator, you may appeal to the Queensland Industrial Relations Commission (QIRC). (Note: your employer can also take this step if they disagree with the review outcome). You must lodge the appeal with the QIRC within 20 business days of the Regulator's decision date and you must serve a copy of the notice to the Regulator within 10 days.
While appealing a decision isn’t as common, with only 0.2 per cent of all WorkCover claim lodgments appealed, there is no cost involved.
To lodge an appeal, you will need details of your claim including:
- Claim number
- Employer details
- Facts relating to the claim
- WorkCover’s reasons for their decision
Due to the complex nature and strict timeframes for appealing rejections, we recommend speaking to a lawyer who knows how to navigate the system as soon as possible.
What types of decisions are reviewable?
The good news is that most decisions are reviewable. As set out in Section 540 of the Act, the types of decisions that can be reviewed include:
- A decision to accept or reject a compensation application
- A decision to terminate or suspend payments
- A decision to increase or decrease weekly payments
- If an insurer fails to decide on a compensation application
- A decision about the time to apply for compensation
However, you can’t request a review of a decision by WorkCover regarding ongoing management of the application for compensation, or a decision not to fund a particular medical procedure.
What does this all mean?
If you’re in the WorkCover system, it can be difficult to understand the various timeframes and applications you’re required to submit. At the end of the day, it’s important to know that if you’ve been injured at work, you do have rights and there are options available to you if you disagree with decisions made along the way.
If you have been injured at work and it’s not your fault, there may be other compensation available to you. Seeking legal advice quickly is recommended.