WorkCover entitlements (Vic)

In Victoria, there are four main WorkCover entitlements. These are:

• Medical and like expenses
• Weekly payments
• Impairment benefit
• Common law claim

Below we summarize all of the four major WorkCover entitlements.

You can also look at this flowchart for a visual explanation of the claims process.

Medical and like expenses

Anyone with an accepted WorkCover claim is entitled to medical and like expenses.

What does this mean?

You are entitled to “reasonable” medical and like expenses.

This can cover a wide range of benefits such as; payment of your GP bills, medication, psychology and physiotherapy.

WorkCover does not necessarily cover the entire bill, but for expenses like your GP or basic medication, most or all will be covered.

Sometimes with larger expenses (such as surgery expenses or dental treatment) there may be a gap between what the WorkCover insurer covers and what the provider bills. So you should ensure to check this before undergoing any medical procedure.

Radiology such as MRIs or CT scans are also covered, as well as consults with surgeons or specialists.

Larger expenses such as surgery do require pre-approval from the WorkCover insurer.

There’s no set timeframe for how long medical and like expenses are payable by the WorkCover insurer for.

Basic entitlements like visits to your GP and simple painkilling medication can continue as long as you have a work related injury and a need for the treatment.

Some services like physiotherapy, chiropractic or hydrotherapy wont be paid forever.

On some occasions the insurer will stop your medical benefits 52 weeks after your weekly payment finish, but that isn’t always the case.

You can read more about medical and like expenses here.

Weekly payments

As long as your doctor or treating health practitioner provides you with valid certificates of capacity stating that you can’t work or are only fit for suitable duties, you are in most cases entitled to up to 130 weeks of weekly payments from WorkCover.

These weekly payments do not cover 100% of your lost wage, and the payment rate reduces over time.

It’s important to make sure that you always have up to date certificates to ensure that your payments are not delayed.

We also recommend that you obtain from the insurer their dedicated email address for certificates and always email your certificates there.

Payments can continue for over 130 weeks if the insurer is satisfied that you have no current work capacity, and that incapacity is likely to continue indefinitely.

This doesn’t mean just looking at whether you are in work or whether someone would hire you for a job, but whether you have a theoretical capacity to do work that you might be suited to do looking at your age, experience, skills and education.

If the insurer stops your payment because the believe you have a capacity, you can have the decision reviewed and challenged.

There’s also the possibility to get ‘top-up’ weekly payments if you have reached the 130-week mark, have a job that you are working at least 15 hours per week in, and you are working to the maximum capacity you can.

Read more about weekly payments here.

An “impairment” lump sum

Anyone with an accepted WorkCover claim can apply for an impairment benefit once their injuries are stable.

When can an injury be considered stable? It’s when the injury is not getting any better and not getting any worse to any significant extent.

To be entitled to a lump sum you must reach a certain level of “whole person impairment”, which is assessed by accredited medical examiners in accordance with strict guidelines.

Not everyone will qualify for a payment.

For example, if you’ve had a knee replacement you will qualify for an impairment lump sum, but a muscle tear that keeps you away from work for a few weeks but resolves after six months very likely will not qualify.

Musculoskeletal claims (including spinal injuries) are treated differently to other physical conditions like scarring or a disease such as Q fever.

Psychiatric injury is also assessed differently from physical injuries.

Once an impairment claim is lodged you will undergo medical assessment by doctors qualified in the American Medical Association 4th Edition Guides to the Assessment of Permanent Impairment.

Their report/s will be forwarded to the WorkCover insurer who will assess your entitlement.

The threshold level of impairment varies based on your type of injury and in the case of some older injuries, on your date of injury.

If you reach the threshold level relevant to your injuries, you’ll receive a payment from WorkCover, which wont effect your entitlement to any other benefits.

Read more about impairment claims here.

Common law claims

What this means in simple terms is suing your employer or another at-fault party when they caused or contributed to the injury you suffered.

Examples of fault that could lead to a common law claim are unsafe systems of work, unsafe or defective equipment being used in the workplace, or unsafe actions taken by a co-worker.

There can be multiple at-fault parties or just one.

In general an employer is responsible for the conduct of employees, so if your injury was caused by a co-worker acting in an unsafe way, the employer is likely to be held responsible for those actions.

You must also show that you have suffered a “serious injury”, which is a legal term.

Outside of severe injuries it can often be hard to know if someone will definitely satisfy the serious injury test.

If you don’t have a serious injury, you cant sue, no matter how strong the negligence claim is.

Claims can either be for pain and suffering only or also include economic loss (loss of earnings).

Whether someone can claim loss of earnings will depend on the individual circumstances of each case and the extent of the loss suffered.

This issue is decided during the serious injury process – you will get either a certificate for pain and suffering only, or for both pain and suffering and loss of earnings.

Getting a certificate doesn’t guarantee you will get a compensation payment as you still have to prove negligence, but if you don’t get a certificate, you’re guaranteed to not get compensation through the common law process.

When assessing what a claim might be worth, each case is unique and as such we recommend trying to not compare your case and what it might be worth to claims you might hear about in the news or from friends.

Many factors need to be looked at, here’s a non-exhaustive list –

• the strength of your serious injury application,
• whether you will be able to claim loss of earnings,
• how clear the claim in negligence is,
• whether there are multiple defendant parties,
• whether there is contributory negligence,
• your pre-injury earnings rate,
• what your doctors and the insurer doctors say about your injuries.

Read more about common law claims here.

A few things to note about the entitlements

In order to access your WorkCover entitlements, you should first lodge and have accepted a WorkCover claim form.

There is a specific WorkCover claim form and, generally speaking, this is the only way for you to initiate a WorkCover claim. Your doctor can’t initiate a WorkCover claim on your behalf, nor can your employer.

Conclusion

There are four entitlements an injured person may have under the Victorian WorkCover system.

These are: medical and like expenses, weekly payments, impairment lump sum, common law lump sum.