WorkCover not paying? Here’s what you can do

There are various situations where WorkCover may not be paying you.

This page will address the different times where you might find WorkCover not paying you and what you can do about it.

There are two broad categories where you may not be getting paid:

• In relation to medical and like expenses
• In relation to your weekly payments.

Firstly, let’s check whether you do have an entitlement:

Have you received a letter or phone call from the WorkCover insurer telling you that your claim has been accepted?

If you have not received such a letter and have no other indication that you have an accepted claim then this will be the reason you are not receiving any payments from WorkCover.

If you have received a notification that your claim has been accepted:

Have you subsequently received a letter, email or other notification from the WorkCover insurer that your entitlement to weekly payments or medical and like expenses has been terminated?

If you have, then this is likely the reason you are not receiving payments.

Finally, if you do have an accepted claim but have not received any notification that your entitlements have ceased, then there will be some other reason for you not being paid.

Medical and like expenses not getting paid

Medical and like expenses are the minimum entitlement that someone on WorkCover can expect to be paid, so in most cases if you have an accepted claim with WorkCover then you have an accepted medical and like expense entitlement. Copyright – this is original content from TheWorkInjurySite.com.au.

There are numerous reasons as to why you may not have received a payment for medical and like expenses:

1. You don’t have an accepted claim or your claim is pending;

If you haven’t lodged a claim you have no entitlement to medical and like expenses.

If you have lodged a claim but it hasn’t been accepted or rejected yet (i.e. it is pending) then your expense payments will be on hold for physical injuries.

New claims for psychological injury will now have some medical and like expenses paid automatically, even before the claim is decided.

You can read more about the WorkCover claims process here.

2. You have not submitted receipts to the insurer for payment;

The insurer can only pay when they are aware of the expense.

So make sure that either the provider is sending their account directly to the insurer, or that you are sending it in yourself and that you are sending it to the correct address.

3. The insurer has not had time to process those receipts;

You can expect it to take 2-4 weeks for accounts to be processed and paid.

Any longer than this you should follow it up with the insurer or engage a lawyer to assist if necessary.

4. The insurer has lost those receipts;

This has been known to happen from time to time. It is always best to use email or if the insurer has an “app”, to use that, so there is no possibility of the receipts being lost.

5. Your employer has been provided with the receipts by you but have not forwarded them on to the insurer;

This can occur for a number of reasons, either unintentional delay due to being busy, placing a low priority on dealing with this type of matter, not understanding what needs to be done or being malicious.

As noted above – it’s always best to send directly to the insurer, to reduce the chance of running into any difficulties.

6. The insurer has decided that you no longer have an entitlement to medical and like expenses but hasn’t notified you or is in the process of notifying you;

When you submit expenses, it will sometimes trigger a review of your entitlement by the insurer, or they may have had a review scheduled for around the same time.

There is no specific timeframe in which a review must be concluded but it does need to be reasonable.

The insurer must provide you with a written decision and your appeal rights if they do terminate your entitlement.

7. You have not submitted sufficient details of the medical expense in order for the insurer to pay it;

Sometimes the insurer will reject payment of an invoice it doesn’t have the required information on.

This can be the case with some pharmacy expenses where there may be specific requirements as to information needed.

If it’s not clear to you what the insurer needs, you should ask them to clarify.

8. The insurer is reviewing whether a particular medical and like expense is covered or should be covered;

You may have an entitlement to ongoing medical and like expenses but the insurer is considering whether to pay a particular expense, for example, something like PRP therapy or major spinal surgery will not be automatically approved, it will be reviewed by the insurer before payment is made.

Weekly payments not getting paid

Some of the reasons that you may not receive weekly payments will be the same as for medical and like expenses.

There are however other instances that are unique to weekly payments as to why you may not be being paid.

1. Your certificates are not valid

There are many reasons why your certificates may not be valid.

Your doctor may not have signed the certificate, or you yourself may have not made the declaration on the back of the certificate.

The period of incapacity may not have been filled in by your doctor or the diagnosis may not have been filled in or specific enough to be acceptable to the WorkCover insurer.

The incorrect certificate may have been used.

For example, if a regular sick certificate is supplied to the insurer it will not be accepted as there is a specific form for work cover certificates of capacity.

2. Your certificate was not provided “on time”

Weekly payments are made for the most part, by your employer.

If you do not submit certificates by the time the pay run is made, you may not receive your weekly payment unless they make a specific payment to you outside of the pay run.

It is always best to get your certificates in at the same time each month.

3. Other reasons

Many of the reasons for not being paid mentioned above for medical and like expenses apply to weekly payments.

You may not have an accepted claim, your insurer may have not had time to process the certificate or may have lost the certificate or if you have only supplied the certificate to your employer they may not have forwarded the certificate to the insurer.

There are strict notice requirements placed upon the insurer in relation to weekly payments which do not necessarily apply to an entitlement to medical and like expenses.

This means that you should not find yourself in the situation where you are submitting certificates and not being paid as the insurer is reviewing your entitlement to weekly payments.

You should always receive a minimum notice period if your entitlements are to cease.

This will allow you to challenge the decision to terminate your payments prior to your payments actually stopping.

It is a very rare circumstance that you would be able to overturn a decision such as this by the time your payments were terminated but at least you can get the process started.

Conclusion

There can be many different reasons that you have not been paid by WorkCover.

Firstly, check that you do have an accepted claim.

If you have established that you do have an accepted claim, check with the insurer whether they have received the expense claim or WorkCover certificate.

If they say there is a decision to stop your payment, they should provide you with a copy of that decision. Keep in mind that you can contest a decision that the insurer makes.