What to do if Your WorkCover Claim is Rejected

WorkCover exists to provide insurance for workers who are injured in the course of their work. Generally, it covers expenses such as a weekly payment, medical bills, rehabilitation and some other costs that may be associated with the injury.

A common misconception exists, that if a worker injures themselves at work they are automatically covered by WorkCover. This, however, is not always the case. Like any insurance scheme, claims for WorkCover may be subject to an investigation and the time off work and medical expenses incurred by the worker may not be covered if the claim is rejected.

Why are claims rejected?

Every matter is different, but some of the frequent reasons claims for WorkCover are rejected include:

  • When the insurer deems that the cause of the worker’s problem was due to a pre-existing medical condition;
  • When the worker did not report the injury within a reasonable time period;
  • When the insurer deems that the worker’s injury was not caused by or did not occur in the course of employment; or
  • In the case of psychological injuries, when the worker was the subject of reasonable management action i.e. a worker cannot make a claim of bullying and harassment simply for having their performance managed, if the insurer finds that the management action was appropriate.

My claim has been rejected. What can I do?

When you are suffering an injury and trying to get your head around why your claim has been rejected it is easy to feel disheartened, deflated and stressed about the future, but if your claim for WorkCover has been rejected and you do not believe that any of the reasons listed above are relevant to your claim, try not worry too much as you have not yet reached a dead end.

Firstly, and most importantly, you should seek the assistance of a workers compensation or personal injury lawyer.

While it is not guaranteed, engaging the services of a workers compensation or personal injury solicitor may significantly improve your chances of having the decision overturned or varied. Workers compensation and personal injury solicitors specialise in this area of the law and are able to navigate these types of claims easily.

How can a lawyer help?

It is likely that your solicitor will advise that you request a review of the decision. You will only have 3 months from the date of the insurer’s decision to request a review with the Workers’ Compensation Regulator, which is responsible for undertaking reviews of insurer decisions including rejected WorkCover claims.

When your claim for WorkCover is rejected, you may be able to request the reason/s why by requesting a Reasons For Decision document within 20 business days of being advised of the decision by the insurer. This document will help the solicitor to prepare your application for a review of your claim as it may indicate that some crucial information was missing or misrepresented in your initial claim for WorkCover.

What is the review process?

The Workers’ Compensation Regulator is an independent body which seeks to provide unbiased reviews of certain decisions made by insurers.

It is not a court process and it will simply involve a Review Officer assessing all of the available information in relation to your claim. You will not be re-investigated and no further information will be requested (however, you may include further information in your application for a review).

Workers can request a ‘Right of Appearance’, which means they will have the opportunity to speak to the Review Officer about their claim. A Review Officer cannot provide any advice to the worker.

Once the review is complete, the outcome may mean the decision is either overturned, varied (meaning some payments may be made) or remains rejected.

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