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My Worker’s Compensation Claim has been rejected. What do I do?

If you have lodged a Workers Compensation Claim and the Insurer has rejected it, there are avenues to appeal this decision. Before any appeal is made, it is necessary to understand why the claim was rejected.

In this article, we will explore the reasons why your Worker’s Compensation Claim may be rejected and the subsequent avenues for appeal.

The WorkCover Insurer may reject your Worker’s Compensation Claim on the following basis:

  1. The WorkCover Claim was lodged within 30 days of becoming aware of the injury. A worker must report their injury to their employer within 30 days of becoming aware of the injury;
  2. The injured person is not a worker as defined under the Workplace Injury Rehabilitation and Compensation Act 2013 (‘the Act’);
  3. The injury did not arise out of or in the course of your employment;
  4. There is no physical and/or mental injury and/or
  5. There is no connection to the State of Victoria.

In addition to the above, for psychological injuries suffered, the Insurer may reject a claim in circumstances where the defence of reasonable management action applies under s 40 of the Act. 

What do I do if my Worker’s Compensation Claim has been rejected?

Conciliation with the Workplace Injury Commission

When a WorkCover claim has been rejected, there are avenues for appeal with the Workplace Injury Commission (WIC).

Immediately following the rejection of your claim, you must complete and return an Application for Conciliation within 60 days of the Insurer’s determination.

Following the return of the Application for Conciliation, the Workplace Injury Commission will provide you with a medical report request form. 

This form is essential in obtaining medical reports from your treating doctors to address issues raised by the Insurer’s rejection. For example, the Insurer may reject your claim because you do not suffer an injury. In such circumstances, it will be necessary for your treating doctors to comment on the nature and circumstances surrounding your claimed work-related injury.

Following receipt of material, the Workplace Injury Commission will schedule your matter for a conciliation conference.

Lawyers are generally not allowed to engage in conciliation conferences. However, at National Compensation Lawyers, we provide in-house conciliation representatives to assist you through this process and to engage in conciliation discussions with the Workplace Injury Commission and the Insurer.

Following a conciliation conference, one of the following outcomes may occur:

  1. The Insurer may make an offer to resolve your claim;
  2. The Insurer may accept your claim;
  3. The Insurer may maintain the rejection of your claim and request a Certificate of Genuine Dispute be issued;
  4. The Insurer may request you be assessed by the Medical Panel.

If a Certificate of Genuine Dispute is issued at conciliation, you will have the opportunity to challenge the Insurer’s decision in Court. There is no time limit in referring a dispute to the Magistrates Court once a Certificate of Genuine Dispute has been issued.

Issuing proceedings in the Magistrates Court

To issue proceedings in the Magistrates Court, your lawyer will prepare a Statement of Claim. This will summarise your matter, provide details of the injury and the circumstances surrounding such, and detail the outcome sought.

Once the Statement of Claim has been prepared and served on WorkSafe/the Insurer, the Court will allocate a date for a Directions Hearing where the matter will be fixed for a Hearing within approximately 12 months.

Parties will have the opportunity to resolve the matter at a Pre-Hearing Conference prior to the hearing. Should the matter fail to resolve, it will proceed to a Hearing, although settlement discussions may continue up to and on the day of the Hearing.

Should the matter involve a medical question in dispute (for example, is the suggested medical treatment reasonable and necessary in the treatment of the work-related injury), then the matter may be referred to the Medical Panel for determination.

At the Hearing:

  • Your Barrister and the Defendant’s Barrister will make opening submissions.
  • You will be called to give evidence. In such circumstances, your Barrister will ask questions about the circumstances of your injury.
  • The Defendant will have an opportunity to cross-examine you.
  • Parties will have the opportunity to call witnesses (co-workers, doctors, medical specialists, etc) and make further submissions.
  • Once the Hearing has concluded, the Magistrate will decide on the matter presented before them.

Following a Hearing

A decision made in the Magistrates Court is binding on all parties. An appeal of a Magistrates Court decision can only be made when the Magistrate made a legal error in reaching their judgment.  Should an appeal be sought, a strict 30-day time limit exists to file such with the Supreme Court of Victoria.

In bringing a matter to the Magistrates Court, it is important to understand the associated risks and consequences. Court proceedings are a costly exercise and should not be entered into lightly. An injured worker must understand the effect of bringing such an action and any risks/consequences an action may have to workers’ compensation entitlements. We recommend understanding the law by speaking with your lawyer before issuing Magistrates Court proceedings.