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How to deal with a WorkCover rejection

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Please note that this post was written for Queensland audiences and the information within may not apply to other regions.

Being injured at work or suffering a work-related illness is frustrating, painful and at times, stressful, particularly if your injury is serious enough you need to take time off to recover. Which is why employers are required to have workers’ compensation insurance like WorkCover to cover lost wages and medical costs associated with the injury.

But of the 91,000 WorkCover claims filed in Queensland each year, not all of them are accepted. According to WorkSafe Queensland, about five per cent of WorkCover claims are rejected by the work injury insurer for a range of reasons.

Why are WorkCover claims rejected? Can you appeal a WorkCover rejection? How do you appeal a WorkCover decision? Read on for more about what to do if your WorkCover claim is rejected.

Reasons why your WorkCover claim may get rejected

When considering your workers’ compensation claim, WorkCover Queensland look at all the facts right down to whether you’re even considered an eligible Queensland worker or volunteer. This gives WorkCover several chances to deny your claim.

The most common reasons why WorkCover claims are rejected include:

  • Your injury or illness is unrelated to your employment
  • You don’t have an injury or illness, whether physical or mental
  • It didn’t happen in Queensland, or doesn’t have a connection to Queensland
  • You don’t meet the definition of a “worker” under the Workers’ Compensation and Rehabilitation Act 2003
  • The illness arose out of reasonable management action (if psychological injury)
  • You didn’t report your injury in a timely way

While it isn’t your employer’s responsibility to approve or deny your claim, your boss is usually consulted during the investigation. If they refute your account of the incident and/or injury, this may also influence WorkCover’s decision.

Appealing a WorkCover rejection

Many get shaken when they see their claim was rejected and presume there’s no merit in pursuing it any further. The good news is an initial WorkCover rejection doesn’t always mean your claim is over. While we know many initial rejections don’t get overturned, if your WorkCover claim is rejected you have the legal right to dispute it.

The process for appealing a WorkCover decision is complex, and how you do this also differs for each state. In Queensland, it’s done through the Workers’ Compensation Regulator.

It’s important to note that there is only a short window in which you can appeal a WorkCover decision. However, there will generally be multiple opportunities for both sides to come to an agreement – and if not, the case will go to court.

Note: Your employer is also able to apply to have the decision reviewed if they are unhappy with it.

How to appeal a WorkCover rejection

Request a review

The Workers’ Compensation Regulator is an independent decision maker separate from WorkCover Queensland that is responsible for reviewing insurer decisions. To lodge a review with the Regulator, you must first find out why your claim was not accepted and submit a review application form.

Along with the review application, you’ll be required to explain why you think WorkCover’s decision is wrong and provide supporting documents. These can be anything from initial incident reports to medical reports. The regulator usually then has 25 business days to decide the outcome.

Note: Data shows that of the decisions that are disputed, 60 per cent uphold the original decision. To give yourself the best chance at being successful, it is recommended to seek legal advice as soon as possible.

Appeal the review decision

As mentioned above, there may be multiple opportunities for both sides to appeal certain decisions and reach a resolution – this includes the ability to challenge a review (although you can only do this once, and that decision is final).

If you still disagree with the decision of the Workers’ Compensation Regulator, you can appeal to the Queensland Industrial Relations Commission (QIRC). This must be done within 20 business days of the Regulator’s decision, and you also have to provide a copy of the notice to the Regulator within 10 business days.

Note: Most decisions are reviewable, meaning if you’re unhappy with almost any decision regarding your WorkCover claim, you are most likely able to have it reviewed.

Read more things you should know about WorkCover claims here.

Other options for compensation if your WorkCover claim is rejected

WorkCover might not be the only option available to you for help. There are other financial safety nets out there that could help you if your WorkCover claim is rejected, like a Total and Permanent Disability insurance claim through your superannuation.

Read more about understanding TPD insurance through superannuation here.