Examples of WorkCover claims rejected

Examples of WorkCover claims rejected

WorkCover claims can be rejected for a number of reasons.

This article will look at a number of examples of WorkCover claims being rejected.

Keep in mind that it’s common for claims to be rejected for a number of reasons.

If yours has been rejected and you’re not sure what to do, this page might help.

Please keep in mind that the examples below are just that – examples for illustration purposes.

Pre-existing condition

Max suffered injury to his left shoulder as a consequence of working in a dairy related food processing company. The injury occurred as a consequence of having to push large blocks of dairy products down a conveyor belt.

He lodged a WorkCover claim which was rejected by the insurance company because it was their position that the injury related was a pre-existing condition.

Factual dispute

Gabrielle was employed as a nurse and suffered a back injury when having to manually move a patient with mobility issues.

She lodged a WorkCover claim. The WorkCover insurer organised an assessment for her to see a doctor. They also engaged a circumstance investigation report.

The claim was rejected as the WorkCover insurer believed that the facts relating to how the injury happened were different to Gabrielle’s version of events.

Unrelated to employment

Don worked for a traffic control and road maintenance company. During the course of her employment, she suffered injury to her neck. She puts the injury down to the repeated heavy lifting she was required to do during the course of her employment.

She lodged a Kate lodged a WorkCover claim. She was sent to an independent medical examiner by the WorkCover Insurer.

The WorkCover Insurer rejected the claim on the basis that the injury was unrelated to work. Kate had mentioned to the WorkCover insurer that she had for number of years played competitive netball and had had the odd problem with her right knee.

The WorkCover insurer, based on the opinion from the independent medical examiner, concluded that the pain and restriction that she was experiencing in her right knee at the moment, which Kate leave was related to her employment, related to The previous knee troubles that she had had.

Question over whether connected to employment

Wayne was employed as a security guard. He worked in a number of roles, all of which required him to perform security work.

During the course of his employment, as a consequence of being involved in an altercation with a patron, he suffered facial injuries.

He lodged a WorkCover claim which was rejected on the basis of serious misconduct, on behalf of Wayne,. There was also an issue about whether the injury was related to work, as Wayne had followed the person that he was involved in an altercation with away from where he was working.

Reasonable management action in a reasonable manner

Kelly was employed working in a large corporate office. As a consequence of ongoing bullying and harassment directed towards her by one of her supervisors, she suffered psychological injuries and had to stop working.

She lodged a WorkCover claim. The WorkCover insurer organised for her to be assessed by an independent medical examiner, and also engaged a circumstance investigated to produce a circumstance investigation report.

The independent medical examiner found that Kelly was suffering from a medical condition that was related to her appointment.

However, based on the circumstance investigation report, the WorkCover insurer rejected her claim on the basis that, the majority of her issues were related to reasonable management action taken in a reasonable manner.

Delay in reporting the injury and lodging claim

Jake was employed by a building organisation. During the course of his employment, he suffered injury to his right wrist and elbow.

Due to not wanting to jeopardise his job, Jack didn’t report the injury to his employer throughout the whole period of time that he was with this enquire.

He left this employer approximately a year and a half after suffering the injury.

He lodged a WorkCover claim after ceasing employment with his employer.

The reason he waited to lodge the WorkCover claim, other than not wanting to impact his employment, was that he was confident that the injury would improve and, in time, disappear. However this did not care.

The WorkCover claim was rejected. One of the reasons for the rejection was that the injury was reported outside of the allowed time frame.

Not a ‘worker’ under the act

Shaun was running his own business. He suffered injury to his wrist while working as a sub contractor in a manufacturing plant.

Shaun didn’t work set hours with this sub contractor – he was largely able to come and go as he pleased. He didn’t get paid based on time worked, and he provided most of his own equipment to perform the work.

Based on the above, his claim was rejected on the basis that he didn’t fall under the definition of a worker under the act.

Conclusion

There are a number of reasons why a WorkCover claim can be rejected. It might be that you’re not considered to be a ‘worker under the act’, due to a delay in reporting the injury or lodging a claim, or because the insurer believes the injury is a pre existing one and not related to employment.

If your claim is rejected, keep in mind that it is not uncommon for claims to initially be rejected. You’re able to appeal the decision, and many times claims that were originally rejected will later on be accepted.

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.

Sidebar graphic of WorkCover benefits guide

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

Written by the Work Injury Site team