What happens when your workers’ compensation claim is initially rejected?
Don’t feel too disheartened, there may be other options to pursue your claim. As this may be a sensitive situation to be in, given it involves your employer, we’ve put together a short guide to help you understand the possible next steps.
Why claims are rejected
There are many legitimate reasons for a claim to be rejected, although sometimes, it might be that WorkCover (or other insurer) determines that the injury or condition doesn’t relate to a person’s work. This could be because incorrect information or advice has been provided.
Whatever their reason for rejecting your claim, WorkCover can provide you with a ‘Reasons for Decision’ to explain why.
If you genuinely believe you’re eligible to claim for compensation and that you’ve been unfairly rejected, your first option will be to dispute the finding by requesting a review.
How to appeal your unsuccessful claim
Once you’ve received your ‘Reasons for Decision’ from WorkCover, you have three months from the date of receipt to lodge your appeal with the Workers’ Compensation Regulator. The Regulator operates independently, and can decide to confirm, vary, or set aside WorkCover’s (or other insurer’s) original decision.
However, if you choose to appeal on your own, you can follow these steps:
Step 1: You will need to fill out the Worker’s Compensation Regulator Application for Review Form or lodge online. Before you lodge your form, you’ll need to complete steps 2 and 3.
Step 2: As part of your application for review, you’ll need to provide your detailed explanation of why the insurer’s decision is wrong.
Step 3: You’ll need to gather and provide any additional supporting documents to your application, such as medical reports and witness statements.
Step 4: You can now sign and submit the application form to the Workers’ Compensation Regulator, ensuring to do so within the 3-month time limit.
The Regulator will make their review decision within 25 business days of you lodging your review. You may be invited to appear, either in person or over the phone, to share your side of the matter.
What happens if your application for review is rejected?
The Regulator can decide one of four outcomes:
- Confirm – the insurer’s original decision doesn’t change (i.e. your appeal is unsuccessful).
- Vary – the insurer’s decision is varied.
- Set aside – the insurer’s decision is changed and the insurer will take the necessary action.
- Set aside undecided – the insurer’s decision is set aside and the matter returned to them with specific instructions they must undertake prior to making a fresh decision.
If you (or the insurer) are unhappy with the outcome of this review decision, you’re able to lodge an Appeal to the Queensland Industrial Relations Commission (QIRC) within 20 business days of receiving your review decision.
You aren’t required to have a lawyer at any stage during your workers’ compensation claim, however, due to the complex nature of injury claims, you might find a lawyer is better able to prepare your appeal.
Talk to us for a free case review
Unfortunately, there are strict time limitations that apply to a workers’ compensation claim, so it’s important you speak to a lawyer as soon as possible to give your claim the best chance for success.
You can get in touch with one of our friendly experts for your free case review for a better understanding of your situation and eligibility to claim.