Rejected WorkCover Claim - What Next?

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For most people who are injured during the course of their work, WorkCover will cover expenses such as a standard weekly income payment, medical and rehabilitation bills and other costs that may be associated with the injury.

Not all injured workers are automatically covered by WorkCover, however, and as is the case with all insurance schemes, WorkCover may choose to investigate the injury claim, the surrounding circumstances and the impact the injuries have or will have on the worker before approving or rejecting it.

If an injury claim is rejected, any medical expenses incurred by the worker or time taken off because of the injury may not be covered by WorkCover.

What can cause a claim to be rejected?

Some of the key reasons why WorkCover may reject a claim include:

  • the insurer determining that the worker’s injury was not suffered during the course of their employment;
  • the insurer determining that the worker’s injury was, or was caused by, a pre-existing medical condition;
  • the worker failing to report their injury within a reasonable timeframe; and/or
  • the claim being unsubstantiated. For example, if the worker makes a claim for psychological injuries caused by workplace bullying but the insurer discovers that the worker was actually the subject of reasonable and appropriate management action, their claim will be rejected.

What are the next steps if a claim is rejected?

A WorkCover claim rejection does not mean it is the end of the road.

If a worker does not believe that any of the key reasons for rejection listed above apply to their claim then they should seek to have their claim reviewed. In some cases, the rejection may have simply been based on the fact that information was left out or misrepresented.

This is why it is important to obtain help from a personal injury lawyer to assist with a claim for WorkCover as they know exactly what is required and how the information should be presented to achieve the best possible outcome.

Why should a claimant seek help from a personal injury lawyer?

Personal injury lawyers handle workplace injury claims every day and are the best people to help handle a WorkCover claim.

If a worker has made a claim without the assistance of a lawyer, they can seek legal advice for help preparing to request a review of the decision.

Timing is critical as the claimant will only have three months from the date that the insurer rejects the claim to request a review with the Workers’ Compensation Regulator. The Regulator is the body responsible for undertaking reviews of insurer decisions, including rejected WorkCover claims.

It is the claimant’s right to request a ‘reasons for decision’ document if their claim for WorkCover has been rejected, and they should do so within 20 business days of the claim being rejected. This document can help a personal injury lawyer prepare an application for a review of the claim. It usually indicates if vital information was missing or misrepresented the first time.

What is involved in the review process?

The review process does not take place in a court. The worker’s claim will simply be reviewed by a Review Officer from the Workers’ Compensation Regulator who will assess all of the information available to them.

No further information will be requested by the Regulator and the worker will not be reinvestigated if they were the first time around.

If desired, a worker may request a ‘Right of Appearance’, which means they will have the opportunity to speak to the Review Officer about their claim, but the Review Officer cannot provide any advice to the worker if they elect to appear.

Upon completing the review, a decision will be made to overturn, reject, or vary the original outcome. A variation means that some payments may be made to the claimant.

If you have suffered an injury during the course of your work and need advice on how to prepare a claim for WorkCover, our experienced injury lawyers in Cairns can assist.