The WorkCover claim process (Vic) (explained)

What is WorkCover?

WorkCover insurance covers the cost of any benefits if employees are injured or they become ill because of their work. It is compulsory for all Victorian employers to have WorkCover insurance, and all employees are covered, regardless as to whether they are full time, part time or casual workers.

Every state in Australia has it’s own WorkCover insurance scheme. The Victorian system is run by WorkSafe Victoria.

What does WorkCover cover?

WorkCover will pay the following benefits to injured workers: medical and like expenses, weekly payments, impairment benefit and in certain cases, a common law claim for damages.

Below is the WorkCover claim process for lodging a claim in Victoria.

Do I meet the criteria to claim WorkCover in Victoria?

If you suffer an injury that arises out of our in the course of your employment, connected to Victoria, you are entitled to lodge a WorkCover claim.

There must be a connection to Victoria

Your employment must be connected to Victoria in some way.

It doesn’t matter whether you suffer injury outside of Victoria or even Australia.

You can establish a connection between your employment and Victoria if;

• You normally work in your employment in Victoria, or if you don’t normally work in Victoria, you’re based in Victoria for the purposes of your employment, or:
• Your employers main place of business is located in Victoria.

There must be an injury

The law defines an injury as any physical or mental injury.

It also includes industrial deafness, a disease contracted during the course of employment, or a recurrence, aggravation, acceleration, exacerbation or deterioration of any pre-existing injury or disease.

It can also be a condition related to workplace stress or bullying.

You must be a worker under the act

A worker is someone who performs work for employer or agrees with an employee to perform work at the employers direction instructional request.

This means whether it’s under a contract of employment or otherwise or someone who is a deemed worker under the legislation.

How to lodge a WorkCover Claim

1. See your doctor.

2. Report the injury.

3. Complete the WorkCover claim form.

4. Lodge the claim form on your employer or WorkSafe.

5. Keep a note of the relevant dates.

Here’s how to make a WorkCover claim in Victoria:

See your doctor:

You should see your doctor as soon as possible for treatment and provide them with details about how you were injured.

Not only will they provide treatment to you, their clinical notes and record of any attendances maybe important in relation to having your claim accepted.

Report the injury:

You should report the injury to your employer as soon as possible. You should ensure to record your injury in the register of injuries book.

There is a requirement that you report the injury within 30 days of becoming aware of it. In practice however, this does not always occur and the fact that you have not reported the injury within 30 days will not prevent you from having an accepted WorkCover claim.

Complete the WorkCover Vic claim form:

This is what the initial form looks like that you need to fill out if you’ve suffered an injury at work and want to lodge a WorkCover claim in Victoria.

Where can you get a copy of the claim form?

You can get a copy of the WorkCover claim form here.

You can also get a copy from WorkSafe, some post offices and in some cases, your GP.

Tips to keep in mind when filling out the WorkCover claim form:

Read each question in Part 2 carefully, and think about your answers.

Your answers here matter not only when the claim is being assessed, but also down the track when you might be bringing a lump sum claim.

When answering how, when and where the accident occurred, keep your answer clear and straightforward. You must link the accident to work.

There’s no need to over-explain, there are always opportunities later to expand on things if needed.

“Have you previously had another injury/condition or personal injury claim that relates to this injury/condition?”

This means have you ever had a similar injury, whether it’s related to work or not. If in doubt, you are better to answer yet and list any old injuries that could be similar.

Be truthful. It’s obvious, but people do get caught out when they aren’t honest on the claim form. There are also potential civil or criminal penalties.

When the form is completed, you must sign it. Note the highlighted section below, which you should be aware of:

Ensure to keep all of the ‘Employer lodgement details’ part of the form blank.

Do I need a lawyer?

To give your claim the best chance of success and getting accepted, it can be a good idea to get legal advice early on – before lodging the claim.

It’s not necessary in all WorkCover matters, however there are very few matters where some initial advice won’t help.

If you want advice from us, feel free to contact us. Otherwise, there are plenty of lawyers to choose from out there.

Read more: I got injured at work, do I need a lawyer?

Lodge the claim form:

In Victoria, you must provide your employer a copy of the WorkCover claim form within 30 days after becoming aware of the injury.

If you do not lodge a claim within 30 days, in some instances your claim will be rejected.

WorkSafe or the insurer may however extend the 30 day time limit if they are satisfied that it was not reasonably practicable to lodge the claim.

In reality, many WorkCover claims lodged outside the 30 day period without issue.

The claim form must be submitted to the employer or alternatively directly to WorkSafe Victoria.

Read more about where to send the WorkCover claim form.

If you can take a photocopy (or even a photo) of your completed claim form before you hand it over to your employer, you should do so.

This will mean that you have a record of the claim form should it ever be lost or not submitted by the employer.

Make sure to record the date that you hand over the claim form.

You should receive a copy of the completed claim form from the employer once they have signed it. If they don’t give you a copy, you are entitled to ask for one.

If you are wishing to make a claim for weekly payments in addition to medical and like expenses, you must include the date that you ceased work due to the claimed injury and your claim must be accompanied by a certificate of capacity (sometimes called a WorkCover certificate).

Weekly payments are not payable unless you have provided a certificate of capacity.

You can read more about WorkCover certificate’s here.

Once the employer receives your claim, they must forward it to WorkSafe Victoria together with your medical certificate within 10 days after receiving the claim. If they fail to do this, there may be penalties.

The claim is then determined by one of WorkSafe‘s authorised insurance companies.

This may be one of: EML, xChanging, Gallagher Bassett or Allianz. Or alternatively, you may work for a company that is a self insurer.

They may require the injured worker to undergo an examination by an independent medical examiner, which the insurer will pay for.

If you refuse to attend an examination then they may reject your claim.

They may also organise for a circumstance investigation report to be completed.

This involves an investigator speaking to key witnesses involved in your matter and producing a report regarding the circumstances of the matter.

It’s important to note that circumstance investigation reports are usually only requested in matters that involve psychological injury and also where there is a significant factual dispute.

The insurer must then give written notice of a decision either excepting or rejecting the claim for compensation within 28 days after receiving it or within 28 days after receiving a medical medical certificate.

If they do not do this the claim is deemed to have been accepted and weekly payments must be made.

If WorkSafe receives a claim for compensation for weekly payments accompanied by a medical certificate from the employer more than 28 days after the expiry of 10 days then the claim is deemed to have been accepted in again, weekly payments must be made.

If you haven’t heard from a WorkCover insurer within 4 weeks of lodging your claim, you should follow up with your employer.

You can also call WorkSafe Advisory on 1800 136 089 to find out if your claim has been lodged with an insurer, or to find out the name of the WorkCover insurer responsible for your employer’s claims.

What happens if my claim is accepted? ✅

You’ll receive notification from the insurance company in writing that your WorkCover claim has been accepted.

You should receive written confirmation from the insurer that they have accepted your claim.

You will also be paid medical and like expenses and weekly payments (if you claimed them).

It also opens the door for you to pursue an impairment benefit and potentially a common law claim if negligence resulted in your injury or condition.

Any entitlements will be back paid to the date of injury.

If you want to view WorkCover payout examples to see what you may be entitled to, you can visit this page.

What happens if my claim is rejected?❌

The two main options that you have to ask the WorkCover insurer to review the decision, or to proceed to conciliation. We recommend proceeding to conciliation because in our experience the insurer really changes their decision when asked to review their decision.

Before electing to go down one of these roads, you should seek legal advice to ensure that there is merit in proceeding further.

Can my employer reject a WorkCover claim in Victoria?

Your employer must send your WorkCover claim documentation to their WorkCover Insurer.

It is the insurers job to accept or reject claims, not your employer.

Your employer can let the insurer know of their opinion in relation to your claim, but they cannot determine your claim.

You can read more about this on our page can an employer dispute a WorkCover claim.

What are some of the reasons why my WorkCover claim could be rejected in Victoria?

There are many reasons why a WorkCover claim would be rejected.

Some of the most common are; that your injury was not caused at work, that you have a pre-existing injury, or that there is a dispute in relation to the circumstances of what happened.

If my WorkCover claim is rejected, what do I do for income if I can’t work?

You may be able to use your leave entitlements (sick leave, annual leave, long service leave) if you can’t work. If your claim is accepted down the track, you are entitled to have any leave taken re-credited to you.

Other options are to use income protection if you have it, or to contact Centrelink.

Is it worthwhile contesting the insurers decision after my claim was rejected?

Generally speaking, yes.

There are many many occasions where a WorkCover claim was rejected and then later accepted either at conciliation or further down the line.

The bottom line is this; if you believed that your injury is in someway connected to your employment, you generally stand a good chance of getting your claim accepted even if it was usually rejected.

What happens if my claim does not resolve it conciliation?

You have to appeal avenues; the first is to proceed to the medical panel.

The second is to proceed to the Magistrates Court.

If there are factual issues involved in your matter e.g.: if there is some dispute as to how the injury happened, then you are not able to proceed to the medical panel and must proceed to the Magistrates Court.

If you are proceeding to the Magistrates Court, we would strongly suggest that you obtain legal representation.

If my claim is accepted at conciliation, are my entitlements backdated?

If your claim is accepted at conciliation then yes the insurer is required to pay you any entitlements from the date of the injury and on going.

That is, you’ll be paid your entitlements as if the claim was accepted initially.

This means that you’ll be paid any weekly payments or medical and like expenses that you would’ve been entitled to.

For this reason, it’s important to obtain certificates of capacity from your general practitioner or other trader (if you are intending to claim weekly payments).

It’s also important to keep a copy of any receipts/invoices/accounts relating to any medical treatment you may have received.

Copyright – this is original content from theworkinjurysite.com.au.

If my claim is accepted at conciliation, is the insurer responsible for paying my costs of contesting their decision?

No, the WorkCover Insurer is not responsible for paying costs In the same way that you would be paid costs if you won a court case, if you are successful in having your claim accepted at conciliation.

You are able to seek reimbursement for the reasonable cost of transport expenses to and from conciliation up to $63 (2021).

How long do you have to lodge a WorkCover claim?

There is no deadline to making a WorkCover claim in Victoria. For example, you can lodge a claim years after an injury occurred and depending upon the evidence, it may still be accepted. However, generally speaking, the earlier you lodge a claim the better. It gives you the best chance of having your claim accepted.

That being said, it’s generally more desirable to lodge a claim as soon as possible after injury occurs, simply because you give yourself the best chance of having a claim accepted, it is possible to lodge claim many years after an injury has occurred.

It all depends upon what evidence exists pointing to the fact that you suffered an injury in the circumstances in which you say the injury occurred.

If there is no evidence to establish that you suffered an injury connected to your employment, this can make it much more difficult to have a claim accepted.

Written accounts of your injury, such as emails, text messages or diary notes can be handy.

Also, anything noted by doctors or other medical and health practitioners that you’ve seen will be important.

There’s also a 30 day notice period in which an employee should notify employer of an injury or illness within 30 days after becoming aware of that injury or illness. The best way to notify an employer of an injury or illness is by using the workplace injury registrar book.

However, it’s understandable that people may not want to report an injury or illness to their employer for fear of it impacting their employment. Even if you do not report the matter to the employer, you can still pursue a claim.

While there is no fixed WorkCover claim time limit in Victoria (to pursuing your no fault entitlements – being medical expenses, weekly payments and an impairment benefit lump sum claim – keep in mind there is a six year deadline in which to bring a common law damages claim.

Read more about how long you have to lodge a WorkCover claim in Victoria.

Conclusion

Before lodging the WorkCover claim form, you should consider whether you want to go ahead with the lodgement of a claim.

If you’re not sure whether to proceed with a claim, this page should help you.

If you’re wondering how long a WorkCover claim takes, you can read about that here.

Ensure to report your injury to your employer. Or if for some reason you don’t feel comfortable doing so, ensure it is recorded somewhere – visiting your local GP and letting them know about the injury is a good idea.

If you’ve decided you want to, make sure you satisfy the three criteria that you need to satisfy before lodging the claim.

The claim form itself is pretty straightforward and you can complete and lodge it yourself if you wish – just make sure to take your time and fill it out carefully.

If your claim is rejected, understand the avenues you need to follow to contest the insurers decision. Don’t get discouraged and think that just because your claim was rejected, there is no point pursuing it any further. Many claims get rejected at first instance and then accepted later on.