What to do when your WorkCover claim is rejected (Vic)

What to do if your workcover claim is rejected

If your WorkCover claim has been rejected, if you wish to appeal the decision of the insurer you can do so by taking the matter to conciliation.

However, there are some other considerations which this page will detail.

It is not uncommon for claims to be rejected

The first thing that you need to keep in mind if your WorkCover claim is rejected is to not think that that’s the end of the line.

It’s common for WorkCover claims to get rejected for a whole host of reasons.

Very common.

More common than you probably think.

Here’s a few of the common reasons why a WorkCover claim may be rejected;

  • You can’t be classed as a ‘worker’ under the act
  • The injury is not related to your work
  • You had a pre-existing injury which is causing your symptoms
  • The injury was not reported or lodged in a timely fashion
  • There is a dispute as to the circumstances of the injury
  • If you’re claiming a psychological injury – because the psychological injury occurred due to reasonable management action taken in a reasonable manner

Later on in this article I’ll look at each of the above reasons and cover (generally speaking) what you’ll need to address.

For now, let’s look at the process that you’ll need to go through in order to contest the decision to reject your claim.

But first…

Do you want to proceed further?

The first thing you need to think about is whether you want to proceed further with your WorkCover claim.

Many people are shaken by the fact that their WorkCover claim has been rejected.

Sometimes people think that because their claim was rejected, that means that there’s no merit in pursuing it further.

I can tell you that your WorkCover claim being rejected probably doesn’t mean there is no merit to it.

Yes, in some cases WorkCover claims are rejected because there really is no merit.

But many times WorkCover claims are initially rejected and then accepted down the track.

One thing you need to keep in mind is that someone has made a decision to reject your claim from the WorkCover insurance company.

And as you go along, your claim gets reviewed by different people. Which means there are opportunities for other people to look at your claim with fresh eyes.

Also, further evidence may be obtained addressing various things (eg: medical or factual issues).

This is what often causes claims that were once rejected to be accepted.

So bottom line is this, don’t be disgruntled if your WorkCover claim has been rejected initially.

Let’s say that you’ve decided to push on, the first step is;

Going to conciliation

Before I get into conciliation and what’s involved, I should mention there’s a step you can take before conciliation but I don’t generally recommend it.

You can ask the insurer for internal review.

Basically this means that someone else in from the WorkCover insurance company will review the decision to reject your claim.

Yes it can be worthwhile asking the insurer to do an internal review in certain cases.

But as a general rule, I don’t recommend going down the internal review road. Your time is better off going to conciliation when your claim has been rejected.

What’s conciliation?

In case don’t know, conciliation is a process where you can dispute decisions made by the WorkCover insurer.

It’s supposed to be informal. It involves you and your representative if you have one (and you should in this case) and a representative from the insurance company.

It also involves a conciliation officer from the Accident Compensation Conciliation Service.

A word on a representative having a representative – it’s a good idea to have a representative for conciliation where your claim has been rejected.

This is because there’s probably very specific reasons as to why your claim has been rejected and the best chance of resolving the claim early at conciliation, rather than having it go on to the next step or beyond, is to have someone negotiate and put your case forward that knows the law.

So engaging a lawyer or WorkCover Assist is a good idea.

By all means though, if you feel comfortable representing yourself – do that.

Later on in this article I’ll go into more detail about what you need to argue (generally speaking) based on the reasons are for your claim being rejected.

Anyway, conciliation can be initiated by lodging a request for conciliation form.

On the form you need to complete your basic details, list whether you’ve got a representative and their details (if you don’t at this point you can always let the ACCS know later).

You also need to list the reason for the conciliation. You can simply just write ‘rejection of claim’.

Once the request for conciliation form has been completed you just need to send it off to the Accident Compensation Conciliation Service.

You don’t need to serve a copy of this form on your employer.

You don’t need to tell your employer or anyone else that you’re going to conciliation.

All you need to do a complete and send the form off.

Once the form has been sent off then the ACCS will send you some correspondence confirming the conciliation details. It’ll confirm where the conciliation is being held, whether it’s in person or over the phone, and a date and time.

They’ll also send you some material about the conciliation process.

Leading up to the conciliation if you have a representative you should hear from them.

If you don’t hear from them a week or so out from conciliation give them a call.

Sometimes when claims have been rejected it’s worthwhile speaking to the insurance company over the phone before conciliation (say a couple of weeks out from conciliation) to see whether there’s any room to negotiate.

Many times they won’t change their original decision in matters involving a rejection of claim.

But sometimes they will.

If for example your matter was rejected due to a lack of medical material, and you’ve since supplied that medical material to them, then there is a possibility that they’ll accept your claim and the matter won’t need to go to conciliation, thereby saving you some time.

If the matter does proceed to conciliation, in a nutshell the way it will work is the conciliator will outline the conciliation process and then the conciliator will ask the insurer to put their case.

Following that your representative will have the opportunity to put your case.

At some point after discussions have been held, the parties will break into private discussions and if there are offers to be made they will be relayed between the parties by the conciliator.

It’s very common in matters where claims have been rejected for the insurer to make offers to settle the case at conciliation.

These offers are usually what’s called limited period offers.

What does this mean?

Well, an example of a limited period offer might be the insurer will offer to pay you weekly payments and medical and like expenses for a period of three months. However, after three months any entitlement you have stops.

If you accept an offer like this at conciliation you need to remember that these offers are final.

Once you accept a limit period offer, this means that you will not get weekly payments or medical and like expenses beyond the agreed to period.

This applies even if your condition gets worse in the future and you need to go off work or you need some form of medical treatment.

If the matter cannot resolve at conciliation (which is probably more likely than not in matters that involve claims that have been rejected) – then the next step if you want to continue pursuing the matter is to go to either the medical panel or to the Magistrates Court.

Keep in mind that if your matter doesn’t resolve at conciliation, again don’t be discouraged!

Don’t think that because the matter hasn’t resolved or that there were no offers, your matter has no merit.

…that is simply not the case.

Many claims will proceed beyond conciliation and then later on be accepted.

So let’s say that you elect to go to the medical panel after conciliation.

In a nutshell, the medical panel involves you being assessed by doctors who review you and then provide an opinion on a medical question.

If your case involves anything more than a medical question – say for example there are factual issues that might be in dispute – then you can’t go to the medical panel.

The alternative to the medical panel is going to the Magistrates court.

Keep in mind that your case is more likely than not to resolve by way of negotiation between the parties rather than running before a Magistrate.

However, because you have a matter that involves the rejection of a claim, it is quite possible that your claim will need to be run before a Magistrate, particularly if there are significant factual issues in dispute.

If you are successful at either the medical panel or the Magistrates Court and your claim is accepted, then you’re entitled to any weekly payments and medical expenses that you would’ve been paid from when your claim was accepted.

Sometimes claims will be accepted on a limited basis which means you only entitled to a limited period of medical and like expenses or weekly payments but this is not the norm.

Let’s take a look at some of the common reasons why WorkCover claims are rejected and what you need to argue in each of those cases.

Why your claim may have been rejected:

Your injury is not related to your employment

Here the insurer is arguing that you may have an injury, but It could be related to something else.

For example, you could have a shoulder injury and you told the independent medical examiner that saw you after your claim was lodged that dislocated your shoulder playing football a few years ago.

That doctor formed the opinion that your current shoulder problems are due to the injuries that you had in the past, then your claim was rejected.

In this case you need evidence. You need medical evidence from your treating doctors or health practitioners (eg: physio).

Your clinical notes will be important that show the history before and after your shoulder injury at work.

If there is factual issues that are in dispute, statements from people that may be able to assist might be a good idea.

The injury was not reported the claim was not lodged in a timely fashion

Usually this reason will not be the primary reason why a WorkCover claim has been rejected.

Generally speaking, If you didn’t report the injury to your employer shortly after it happened, that doesn’t mean you shouldn’t have an accepted WorkCover claim.

It may mean that the insurer requires more evidence to prove that you suffered an injury in the way that you say you did.

What you’d need to do here is obtain material that documents the injury. For example, treatment history notes from the hospital where you attended or clinical notes from the GP you attended after the injury.

Keep in mind that many people don’t report injuries (although they should) straight away with their employer for a variety of reasons.

Many people don’t lodge WorkCover claims straight away for a variety of reasons.

But these things don’t mean that you won’t have your claim accepted after it’s been rejected.

There’s a dispute as to the circumstances of the injury

Sometimes when a WorkCover claim is lodged the circumstances as to how it occurred is disputed by the employer or another workmate, for example.

Sometimes, the only way to resolve these matters is for the case to be heard before a Magistrate who makes a decision after hearing all of the evidence.

Sometimes what can happen is, as the case goes along but before it court, further evidence can be obtained – perhaps from another worker – who can support your side and that can result in claims being accepted.

Not a worker under the act

This is not a common reason for rejection of a claim but it does happen from time to time.

Sometimes the insurer will argue that you are not a worker under the law.

An example of this might be if you were running your own business and you were employed under a trust rather than a company.

The insurer may argue that you’re a contractor rather than a worker.

There’s a full set of guidelines on the WorkSafe website as to when someone could be considered a worker, and when someone could be considered a contractor.

Go through the guidelines and see what applies to your situation.

Reasonable management action taken a reasonable manner

This only applies to claims involving psychological injuries.

Basically what this ground for rejection is saying is that you may have a psychological injury and it may even have been caused by your employment.

However, the argument here is that the injury arose due to reasonable management action taken in a reasonable manner.

So for example you may have been the subject of disciplinary action, or your hours may have been changed and that’s the cause of the injury.

In cases like this you need to show that it was not these things that caused the psychological injury but other things in the workplace such as bullying or harassment or other unreasonable conduct.

If my WorkCover claim has been rejected, do I have to appeal the decision straight away?

No you don’t, but it’s a good idea to.

First thing you need to do to contest the decision to reject your WorkCover claim to lodge a request for conciliation.

A request for conciliation should be lodged within 60 days from when the decision was made.

However, it’s pretty common for conciliation requests to be lodged outside the 60 day period. You just need to have an adequate reason as to why you’re outside the 60 day period.

So for example a reason might be that you didn’t want to pursue the rejection of your claim just at the moment.

You may have wanted to wait until you had some more clarity regarding your injury and what treatment you might need.

Keep the 60 day period in mind, but if you need to lodge outside that period you should be ok.

What time frames are involved if my WorkCover claim has been rejected?

Once your claim has been rejected, and assuming that you lodge a request for conciliation to appeal the decision, you can expect to go to conciliation within 4 to 8 weeks, or thereabouts.

Sometimes it might be quicker and in rare cases it might be take longer than this but generally speaking that gives you an idea.

If the matter doesn’t resolve at conciliation and you go to the medical panel, that will take roughly another 4 to 8 weeks to get there.

The panel will then hand down their opinion which you should be notified of within about four weeks from the date you attended the panel.

If your matter doesn’t resolve when and you elect to go to the Magistrates Court, then you can expect a delay of about six months or more. Unfortunately this delay is inevitable and there’s not much you can do about it.

Keep in mind though that if you have a representative your matter can be negotiated and possibly resolved prior to the court hearing date.

If you’d like to know about how long different parts of a WorkCover claim generally take, you can read about that here.

If my WorkCover claim is rejected and later gets accepted – what happens?

If your WorkCover claim is initially rejected and then accepted later on, whether that be at conciliation, after going to the medical panel or the Magistrates Court, you’re entitled to be paid what you would have received if your claim was initially accepted.

So if you were claiming weekly payments, you would be back paid weekly payments from when they would have commenced if your claim was accepted.

The same applies for medical and like expenses. Any medical expenses that you would’ve been paid by the insurer if your claim was accepted will be paid to you and to any doctors or health providers who have treated you.

You will then be entitled to the payment of weekly payments ongoing, if you’re claiming them, as well as medical and like expenses.

What do I do with any medical bills if my claim has been rejected?

You should keep any medical related receipts relating to medical treatment that you’ve paid for. If your claim is later accepted, then you’ll be entitled to have these paid.

Should I get certificates of capacity after my claim has been rejected?

If you’re intending to claim weekly payments, even though your claim has been rejected you should continue to see your doctor and obtain certificates of capacity.

This is because if your claim is accepted down the track, you will need valid certificates or capacity covering the periods that you want to claim weekly payments for.

Sometimes doctors will backdate certificates of capacity but you shouldn’t rely upon this and it’s much easier to go to your doctor and get certificates of capacity as you go along.

Do I need to let my doctor or other treating practitioners know that my WorkCover claim has been rejected?

No you don’t need to but it doesn’t hurt to so.

Particularly if your WorkCover claim was rejected for a medical reason, it may be that your doctor may need to provide a medical medical report or a copy of your clinical notes to assist to have the decision overturned.

So giving your doctor a heads up about this isn’t a bad idea.

If I can’t work and my claim is been rejected, what do I do for income?

If you’ve got sick leave or annual leave accrued then you can use these entitlements.

Once your claim has been accepted, then you’ll be entitled to have any entitlement re-credited to you.

If you’ve got no sick leave or annual leave, if you’ve got income protection for a policy you can consider using that.

The final option is to speak to Centrelink.

Unfortunately other than these options, there aren’t really any other options to cover you. For this reason it’s important to appeal the decision to reject your WorkCover claim as soon as possible and to push things forward as quickly as possible.

Conclusion

Just because your claim has been rejected, doesn’t mean there isn’t merit in pursuing it further. Many WorkCover claims are rejected at first instance, only to be accepted down the track.

If your claim has been rejected and you want to appeal the insurers decision to do so, you can lodge a request for conciliation. If the matter doesn’t resolve at conciliation, then there are options open to you beyond that.

 

Please keep in mind that the information contained on this page should not be considered legal advice and no content on this site should replace the need to obtain advice tailored to the specific facts of your case. The facts of a case can significantly alter the advice that can provided. This site only provides general advice. Read more here.

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To contact Michael or Peter call 1800 746 442 or email [email protected]

Written by the Work Injury Site team