What you need to know if you have a pending WorkCover claim (Vic)

WorkCover claim pending graphic

Once you lodge a WorkCover claim in Victoria, it will be sent off to an insurance company who will be responsible for determining the claim.

They need to decide whether to accept or reject your claim.

Generally speaking, the WorkCover insurer has 28 days to give a written notice of a decision either accepting or rejecting the claim.

In some cases, if they do not do this the claim is deemed to have been accepted and weekly payments must be made to you.

What happens during the determination process

During the determination process, the WorkCover insurance company will likely require you to be assessed by an independent medical examiner.

If you have a shoulder injury or a back injury you may be asked to see a general surgeon or an orthopaedic surgeon for example.

If you have a psychological injury then you’ll be asked to see a psychiatrist.

The insurance company is required to pay for the costs of the assessment. includes the assessment cost as well as any travel related expenses that you may incur.

You are also entitled to claim any lost income as a consequence of attending the appointment.

You will need to attend this appointment because if you do not there is a decent chance that the insurer will reject your claim.

The insurer may also organise for a circumstance investigation report to be completed. This involves an investigator organised by WorkCover speaking to people involved in your matter and then producing a report regarding the circumstances of the matter.

Once the insurer has obtained all the material, they will advise you in writing as to the determination.

How do I get paid during the determination process?

Many people don’t realise that even though they have a WorkCover claim that is being determined, that they are still allowed to work with the employer that they suffered injury with.

Whether that means remaining on full duties, full hours, partial hours, or modified duties, you are are allowed to work whilst a WorkCover claim is being determined (and for that matter, whilst you have a WorkCover claim on foot).

If a person remains at work working the same number of hours as they were before they lodged the WorkCover claim, then of course they will be paid income.

In some instances however, a person may only be able to work reduced hours, and there is a shortfall between what they were earning before the injury/WorkCover claim.

In this instance, it is possible for a person to be partially paid for the work they are doing and to take leave for the remainder of the lost time.

For example, say that as a consequence of a work injury a person is only able to work at 50% capacity.

They are able to then take the remaining 50% as leave – whether that be sick leave or annual leave or long service leave.

Once the WorkCover claim has been accepted, then their leave entitlement can be re-credited.

If a person however is not able to work during the determination process, there are a couple of options open to them.

A person in this instance is able to take any sick leave that they have accrued and once the WorkCover claim has been accepted, as in the example above, any leave taken can be reimbursed.

If they don’t have sick leave accrued then they are in some instances able to take annual leave and or long service leave if the employer is amenable to paying same.

It is possible also for a person to obtain income protection payments via their superannuation. However, the reality is that it can take many weeks or longer for an income protection claim to be approved by a superannuation fund and so in reality an income protection benefit is of little use in most cases in the early part of a WorkCover claim.

Can I withdraw my WorkCover claim while it is pending?

If you decide during the claim determination period that you no longer wish to proceed with a WorkCover claim, then yes you are able to withdraw the claim.

This is even if you have gone through the assessment process as described above.

In order to withdraw your claim you should contact the WorkCover insurer directly and let them know.

You should not be billed for any expenses related to the processing of your claim.

What else should I know when my WorkCover claim is pending?

If your ability to work is impacted, you should ensure that you obtain certificates of capacity from your doctor.

Yes, you can obtain these once your claim has been accepted and have them backdated, however it is easier obtain them as you go. You will not be paid weekly payments when your claim is accepted unless you have obtained valid certificates of capacity.

If you require medical treatment, you will need to pay for this yourself whilst your claim is being determined. Ensure to keep a record of receipts/accounts/invoices which you can claim back once your WorkCover claim has been accepted.

Unfortunately, whilst your claim is pending, the WorkCover insurer will not pay for any medical treatment so providers that you see cannot bill the WorkCover insurer directly. However once your claim gets accepted, in many instances you are able to do this.

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.

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

Written by the Work Injury Site team