What to do if your WorkCover claim is rejected?

If you’ve been injured at work in Victoria and you’ve lodged a WorkCover claim which is rejected, you can refer the WorkCover insurer’s decision to the Accident Compensation and Conciliation Service (ACCS) for review. In this article we will detail how you appeal to the ACCS and the possible outcomes of appealing a rejected WorkCover claim.

There are a number of reasons the insurer may reject your claim. We explore some of the primary reasons in our blog, “Why has WorkCover rejected my workers compensation claim?”

You must complete and sign the Request for Conciliation Form which can be found on the WorkSafe website here. You must then email the form with your supporting documents to the [email protected]

The ACCS will provide you with an acknowledgement letter and the Medical Report request form. The Medical Report request form is often overlooked but is very important. This form is used to obtain medical reports from your treating doctors to address specific questions and issues raised in the rejection notice from the WorkCover insurer. For example, if the insurer rejects your claim on the basis that you do not have an injury, the report request requires your doctor to provide your diagnosis, and the nature and extent of your injury.

You must sign the Authority contained in the form and provide it to your treating doctors. This maximises your chances of a successful outcome. The WorkCover insurer will be required to pay the cost of reports from your treating doctors. You will be required to follow up your doctors to ensure these reports are provided.

The ACCS will then arrange a conference date which involves a representative from the WorkCover insurer, your employer, your representative and you. Your representative is not your lawyer. Lawyers are generally not allowed to engage in conciliation discussions. This is an odd rule. Our understanding is that it is meant to ensure that the discussions are not argumentative and that the worker is supported and given an opportunity to be heard without incurring legal costs.

So, who is your representative? On the Request for Conciliation Form, you must elect who you are seeking assistance and support from. The options given are WorkCover Assist, Union Assist or a union representative.

Most workers will be represented by WorkCover Assist and those linked to a Union can access either Union Assist or a union representative. The major unions have their own representatives, the smaller ones don’t. Whichever you fall within, you are always entitled to have a representative attend with you.

There are some occasions where the ACCS engages in an early resolution process (prior to needing to proceed to a conciliation conference), which requires the WorkCover insurer and/or employer to respond within 14 business days. Failing meeting that time limit means the matter will be booked in for a conference. An early resolution process is often engaged if the WorkCover insurer has failed to pay medical expenses or weekly payments that it has agreed to pay.

The following outcomes may come from the ACCS conference:

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

An offer is made to resolve your claim

You can either accept or reject the offer to resolve or you can make a counter-offer. You should seek legal advice before accepting any offer as any acceptance may have a significant impact on your future entitlements.

The insurer accepts your claim

This is great result. You will now be entitled to statutory benefits including:

• • weekly payments;
  • medical expenses; and
  • an impairment benefit claim (a lump sum payment).

The insurer maintains the rejection of your claim

You will be asked whether you agree with this before it is finalised. A Genuine Dispute certificate allows you to challenge the rejection at court.

This is a situation where your lawyer can be your representative.

A Genuine Dispute Certificate also allows you to make an application for independent review with the Workers Compensation Independent Review Service (WCIRS) which was established in April 2020.

There are current reforms to this process, introduced by the Workplace Injury Rehabilitation and Compensation Amendment (Arbitration) Act 2021 (Vic), due to commence in 2023. This will be the subject of a later article.

The insurer requests your claim be assessed by a Medical Panel

You will be asked whether you agree with this before it is finalised.

A Medical Panel makes a final and binding decision. A Medical Panel can only determine medical questions. Most claims rejected for medical reasons would be referred to the Medical Panel. There are limited appeal rights to workers who receive unfavourable Medical Panel opinions. You should speak with a lawyer before proceeding with this option.

You can learn more about Medical Panels in our article “The Role of Medical Panels in Workers’ Compensation Claims”.

If you’ve been injured at work and lodged a WorkCover claim that’s been rejected, we recommend you seek legal advice from a lawyer experienced in workers compensation. At Polaris, we offer a free consultation so you can find out, at no cost to you, exactly where you stand. Call 1300 383 825 to arrange a consultation.