What happens when a WorkCover claim is accepted?
Once your WorkCover claim has been accepted in Victoria, that will entitle you to two things only.
The first is the payment of weekly payments of compensation if your ability to work has been impacted. The second is the payment of reasonable medical and like expenses.
There are other entitlements under the WorkCover scheme, but you are not automatically entitled to access these simply because your initial WorkCover claim has been accepted.
This page will explore the above in detail.
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Is your WorkCover claim actually accepted?
This might seem like an obvious point to address, but it is worthwhile going over.
Many people mistakenly believe that their WorkCover claim has been accepted when it has not.
This is understandably so because lots of people have never had anything to do with the WorkCover system before.
For example, some people might go to the doctor after suffering an injury and the doctor might provide them with a certificate of capacity which they then provide to their employer.
They might believe that have an accepted WorkCover claim because of this.
Similarly, a person might mention to their employer that they have suffered an injury and they therefore assume that this is how a WorkCover claim is lodged and accepted.
A WorkCover claim is only lodged if you have completed the required work cover claim form document and this has been lodged.
That is, you have received confirmation from a WorkCover insurer that your claim is being processed.
The WorkCover claim is only accepted if you have received confirmation from the WorkCover insurer that your claim has been accepted.
You should receive a WorkCover claim acceptance letter from the insurer confirming that your claim has been accepted.
You should be provided with a WorkCover claim number which is a very important number which you should ensure to keep a note of it.
You are entitled to two things once your claim has been accepted
As referred to above, once your WorkCover claim has been accepted you are only entitled to two things.
- The payment of reasonable medical and like expenses
- Weekly payments
1. Payment of reasonable medical and like expenses
The medical and like expenses payable by the WorkCover insurer are wide ranging.
In general, they will pay for things such as GP attendances, physiotherapy, chiropractic treatment, surgery and post surgical care, travel and accommodation.
2. Payment of weekly payments
You’re entitled to claim weekly payments if your ability to work is impacted as a consequence of a work related injury or illness or condition.
So if you can’t work to the same extent that you did previously and you need some time off work, or you can’t work at all, then you’re entitled to claim weekly payments from the WorkCover insurer.
In a nutshell however, you are entitled to be paid at the rate of 95% of your pre-injury average weekly earnings (PIAWE) for the first 13 weeks and thereafter you’re entitled to be paid at the rate of 80% up until 130 weeks.
Some people are entitled to pay be paid beyond 130 weeks if they can show they’ve got no work capacity and this is likely continue indefinitely.
If the person was receiving overtime or shift allowances prior to the injury occurring then they are entitled to have these factored into the pre injury average weekly earnings calculation for the first 52 weeks.
In order to claim weekly payments you will need to obtain certificates of capacity from a medical practitioner or health practitioner and ensure that you continue to provide certificates of capacity during the period where you’re trying to claim weekly payments.
Potential for make up pay/top up pay
In some instances you’ll also be entitled to claim make up pay/top up pay bringing your payments up to 100% for a specified period of time.
The thing to keep in mind is that some people are entitled to top up payments because it is specified in their EBA or other agreement.
Top up payments can obviously pay the difference between what you are getting on WorkCover (whether that be at the 95% or 80%) and what you would have been receiving had you not suffered your injury.
Employment entitlements once your WorkCover claim has been accepted
You can read about the employment entitlements and WorkCover here.
Your long service leave also continues to accrue.
Sick leave however will not accrue while you’re on WorkCover payments. You can be on WorkCover and accrue sick leave however but sick leave will accrue only based on the hours worked.
While on WorkCover payments you are entitled to be paid superannuation contributions after 52 weeks.
The remaining WorkCover entitlements
As mentioned above, just because you have had a WorkCover claim accepted does not mean that you are entitled automatically to all of the potential entitlements under the WorkCover scheme.
An accepted WorkCover claim just entitles you to the payment of medical expenses and weekly payments.
There are, generally speaking, two further entitlements.
The first is an impairment benefit lump sum and the second is a common law claim.
Impairment benefits
The impairment lump sum claim is a claim that a person is entitled to pursue if they have suffered permanent impairment related to their employment.
You can claim for physical injuries, psychological injuries, and other diseases and conditions.
A person must wait until all of the injuries, illnesses and conditions that they are trying to claim have stabilised. You can read about stabilisation here.
Generally speaking, this is a minimum of 12 months from when the injury occurred.
In order to initiate an impairment claim, you need to complete and lodge a specific impairment claim form.
You will then go through a process whereby any injuries are you are claiming for need to be assessed by specialist doctors and your whole person impairment rating will need to be determined.
Common law claim
Common law claims are different to impairment claims and again in order to issue a common law claim, like an impairment claim you need to specifically apply for it.
Again, like an impairment claim, your injury needs to be stablised.
This is because what you were getting compensated for is any permanent impact an injury has on your life.
Common law claims are usually pursued after a person has gone through the impairment claim process and finalised their impairment claim.
And it doesn’t really matter whether a person succeeded in obtaining an impairment benefit lump sum.
A person can fail to obtain an impairment lump sum and still succeed in a common law claim.
The first step to initiate a common law claim is for a serious injury application to be lodged.
You must obtain a serious injury certificate.
You will succeed in doing so if you satisfy the definition of a ‘serious injury’.
The two things that you must prove in relation to a common law claim to succeed is that you have a serious injury and that there was negligence on behalf of another party which contributed to your injury.
If you’re successful you can be compensated for pain and suffering and potentially economic loss.
If the Insurer makes a decision you disagree with
Once your WorkCover claim has been accepted, the insurer may make a decision you disagree with.
For example, they might refuse to pay for a particular type of medical treatment or surgery. Or they might terminate your weekly payments.
If so, you can appeal the decision of the insurer.
The first step in doing so that we recommend is by pursuing the matter to conciliation.
You can read about conciliation here.
If the matter fails resolve it conciliation then there are options beyond that.
Conclusion
The first thing you need to ensure is that that your WorkCover claim has actually been accepted. Many people believe they have an accepted WorkCover claim when in fact they don’t.
If your WorkCover claim has actually been accepted, then you’re entitled to two things.
The first is having the cost of reasonable medical and like expenses paid.
And the second is weekly payments.
In general there are two further entitlements under the WorkCover scheme. The first is an impairment claim and the second is a common law claim for damages.
Just because you have an accepted WorkCover claim does not mean that you’re entitled to these two lump sums. If you wish to claim either or both of them, then you’ll need to make specific applications over and above an initial WorkCover claim.
If the insurer makes a decision in relation to the weekly payments, medical expenses and in limited cases an impairment claim, you can appeal that decision by the conciliation process in first instance.
