Has your workers compensation claim been rejected? Don’t worry, it’s not the end.
If you’ve been injured at work, it’s crucial you receive adequate compensation. A workplace accident can put you in dire straits both physically and financially, so a fair compensation goes a long way to alleviate the situation. However, not all claims are approved.
In fact, NSW government figures record that more than 2,500 claims were rejected in the financial year 2022/23. Many people get disheartened when they receive the dreaded letter of claim denial, but your fight for justice shouldn’t stop there.
There’s plenty you can do to further your claim, even after its initial rejection. Our team of expert workers compensation lawyers can help you through the process. Read our guide below to find out what to do after your workers compensation claim is rejected, and why giving up is not an option.
What is a Section 78 Notice?
If your workers compensation claim gets rejected, chances are you’ll be sent a Section 78 notice by your employer’s insurer. This takes the form of a document (either a letter or email) outlining why your claim has been denied and the reasons for this decision.
In line with the Workplace Injury Management and Workers Compensation Act 1988, a Section 78 notice should include the following:
- Information of your initial claim
- Clear reasons why your claim has been denied
- Supporting evidence and attachments
- Your workers’ rights on the matter
- Guidelines on how to proceed with a review
A Section 78 will notify you of your claim’s rejection, including any discontinuation or reduction in weekly payments or medical expenses.
Why Do Workers’ Compensation Claims Get Denied?
Although it may feel like it, the insurance company isn’t rejecting your claim out of spite. There are reasons for their decision, which they should outline in your Section 78 notice. Workers like yourself get their claims denied for all sorts of reasons, so it’s worth understanding a little more about why your claim may have been rejected.
1. Not Considered a Worker
If your workers compensation claim has been rejected, it may be because you’re not considered a “worker” under the relevant legislation. If you don’t meet the criteria for a “worker” under your employer’s insurance scheme, your claim and subsequent appeal will be denied.
The insurer SafeWork NSW defines a “worker” as “anyone who performs paid work in any capacity for an employer, business or organisation”. That said, the term also includes volunteers, apprentices, and students on work experience. Always consult your insurer’s website for more details on whether or not you are considered a worker.
2. Discrepancies in Details
Although your employer is not responsible for your workers compensation claim, any differences in yours and your boss’ version of events regarding the injury may lead to a claim denial. In other words, if your employer disputes your story, you could see your claim rejected.
Common discrepancies include the cause of your injury, where the incident occurred, and the timing of the event. Gather as much evidence as possible and discuss the details with your boss before submitting your claim to avoid any disputes later in the process. Employers may dispute your claim if they have reason to believe you’re falsifying information.
3. Injuries Sustained are Unrelated to Work
If your injuries are unrelated to work, or deemed as such by the relevant authorities, you will find your workers compensation claim rejected. Non-work injuries include those that occur outside your typical work duties, those that occur during work hours but are sustained off-site, and any incidents involving recreational activities.
A notable example of this involves the former ABC presenter Maryanne Demasi, who had her workers compensation claim rejected after breaking her hip while on a morning run. Both the insurance scheme Comcare and later the Administrative Appeals Tribunal (AAT) rebuffed her claim, citing that her 9:30am run could not be considered an “ordinary recess” from work.
Therefore, it’s exceedingly important that you demonstrate a clear connection between your injury and your work duties in your initial claim or subsequent appeal. If your condition has nothing to do with your job, your claim will be denied.
4. Injury Was Not Reported on Time
To ensure your workers compensation claim has the best chance of succeeding, you must report your injury in a timely manner. This usually means you have to notify your employer within six months of the injury or illness. Once you’ve seen a doctor and assessed your medical situation, fill in a claim form for your workers compensation scheme as soon as you can.
If you fail to report your injury, illness, or condition within a certain time frame (again, usually around six months after the injury occurred), your workers compensation claim will be rejected. For more details on the correct reporting procedure, read our guide on how to claim workers compensation.
5. Pre-Existing Injuries and Illnesses
A final reason as to why you might find your workers compensation claim rejected involves pre-existing injuries or illnesses. Workers cannot claim compensation – neither sick pay nor medical expenses – for any injuries or illnesses they develop before starting their current role.
Your claim must relate to an injury, illness, or condition (certain insurers also cover mental health conditions) sustained as a direct result of your current role. Any injuries that predate your ongoing job cannot be compensated. That said, you can still claim for pre-existing injuries if your current role aggravates or exacerbates the injury.
Can I Dispute a Rejected Workers Compensation Claim?
In short, absolutely you can. Even if your company’s insurer denies your initial workers compensation claim, the issue is far from over. Below, you’ll find guidelines on the various ways you can appeal a rejected workers compensation claim.
Request a Review From the Insurer
The first point of call after your initial claim has been denied is to contact the insurer and request a review. Get in touch with them to express your concern and the insurer should send you a form for the review. Fill this out and include any additional information relevant to your case.
Your insurer must then respond within 14 days, after which they must either overturn, modify, or maintain their original decision. After a review, you may find your claim granted. If you are rejected again, however, don’t panic. You still have a few more places to turn.
Get in Contact With the IRO
If you are dissatisfied with the process at any stage, you can contact the Independent Review Office (IRO) for help. They can provide assistance with your workers compensation claim appeal and can even contact the insurer on your behalf, which takes away a lot of pressure.
There are several ways you can contact the IRO, including via their online website, by email, or by phone. Call them on 13 94 76 or send an email to email@example.com.
Lodge an Application to the Personal Injury Commission
Alternatively, you can always lodge a dispute application with the Personal Injury Commission, an independent organisation based in New South Wales. They offer help resolving work disputes regarding compensation, medical expenses, permanent impairment, and other injury-related issues.
Head to their online portal to submit your application, or get your attorney to do it if you’re legally represented. Include as much relevant information as you can, as you may not be allowed to add details later in the process. Once the Commission has received your application, it will be assigned to one of four dispute resolution pathways and dealt with accordingly.
What is the Time Limit to Dispute a Rejected Claim?
Once your claim has been rejected, you have a specific timeframe within which you can lodge your dispute. This is generally 60 days from when you receive the insurer’s decision. However, this time limit varies from state to state and will also depend on your employer’s insurance scheme. As such, it’s crucial that you seek proper legal advice to help you with the dispute process.
How can Alliance Compensation & Litgation Lawyers help?
In order to be successful in getting an insurer’s decision amended, it is important that the section 78 notice is thoroughly reviewed. In most cases, the insurer’s decision can be difficult to understand without expert advice. That’s why we are here to help. The team at Alliance Compensation and Litigation Lawyers have successfully overturned hundreds on insurer decisions.
After we thoroughly review all the evidence the insurer has put forward, we will be able to assess the validity of their decision and provide you with advice on your next steps.
In most cases, the first step to trying to overturn an insurer decision is by completing an application for review by the insurer. The application should outline the reasons why you think the insurer’s decision is incorrect or should be amended. Evidence should be gathered and attached to the application. At this stage, we would take a worker’s statement from you as evidence to attach to the application.
The rest of the evidence depends on your case. For example, if the dispute is on the basis that you are not a worker as required by the workers compensation legislation, then we would need to gather proof of employment such as an employment contract, payslips and tax returns. Whereas, if it a dispute about whether surgery is reasonably necessary, we would need to obtain medical evidence, treating doctor reports and potentially a specialist independent medical examination report.
The insurer has 14 days to review their decision once an application for review has been sent.
If the insurer’s decision is maintained upon review, then the next step would be to refer the matter for a dispute before the Personal Injury Commission.
Submit a Claim with Alliance Compensation & Litigation Lawyers
At Alliance Compensation & Litigation Lawyers, we provide exceptional legal services to help you get the justice you deserve. We offer a much-needed hand to you for all your workers compensation needs.
Our lawyers are experts in their field. They can help you through tough times by alleviating any legal pressures and daunting situations that inevitably arise from a workers compensation claim. What’s more, we can get you the guidance you need even if your claim is rejected, and navigate the whole dispute process for you.
In other words, having legal representation is extremely beneficial. So, what are you waiting for? Contact us today to book a free, no-obligation consultation and get the help you need.
Frequently Asked Questions
What is the Time Limit for Reporting a Workplace Injury?
Any workers compensation claim must be submitted within six months after the injury or incident occurred. Generally, though, you should aim to make the claim as soon as possible, since delaying it can impact your eligibility for compensation.
It’s possible to delay the time limit for reporting a workplace injury, but only in certain circumstances. These include absence from the state, logistical mistakes, and if you don’t become aware of the injury until a later date. Where a reasonable cause for not making the claim earlier is accepted, the time limit may extend to three years.
Can I Reopen my Workers Compensation Claim After it’s Been Rejected?
If your workers compensation claim has been rejected, you can dispute the decision. To reopen your case, contact the insurer directly and ask for a review. They should send you a form to fill in, to which you should attach any relevant additional information to improve your claim.
You could also contact the Independent Review Office or the Personal Injury Commission with details of your claim and dispute. However you choose to reopen your workers compensation claim, make sure you have legal representation, as the dispute process can be daunting if you don’t.
How Do I Avoid My Workers Comp Claim From Being Rejected?
To prevent your workers compensation claim from being rejected, make sure you include as much relevant information as possible. Seek medical attention promptly, so you can use doctor’s notes as evidence in your case. Consult with your boss, too, to avoid any potential discrepancies in your accounts.
It’s worth getting legal representation at this stage, since lawyers can help boost your claim’s chances of being accepted. Plus, you’ll be legally covered should your claim be denied and you need to apply for a review.