Workers Compensation Entitlements

worker compensation entitlements

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Workers Compensation – Liability disputes

Workers Compensation Entitlements. It is not uncommon for insurers to dispute liability for your workers compensation claim or an aspect of your claim. An insurer may stop weekly payments and decline to pay for your medical expenses if they gather evidence to show that they are not responsible for part of or your entire claim.

Insurers generally may reject a claim relating to issues such as whether the injured person was a worker or a deemed worker at the time of the injury, whether the injury happened at work and whether work was a substantial contributing factor in causing the injury. When lodging a claim, the answer to these questions may seem straight forward. However, the insurers can reject claims by interpreting and applying the terms of the Workers Compensation Act and Workplace Injury Management and Workers Compensation Act 1998, which can be quite technical and complex to contest without appropriate knowledge of the law.

The most common reasoning an insurer provides when disputing a claim for medical treatment is that the medical condition is pre-existing, or the claimed treatment is not reasonable or necessary.  Typically, the insurers obtain a report from a doctor to suggest that the need for treatment is either due to a pre-existing condition or due to old age (degenerative changes), rather than because of the work-related injury.  Some doctors may also say the treatment is not reasonable or necessary, meaning it will not benefit the injured person even if they receive the treatment.

If the owner or occupier has not taken reasonable steps to protect your safety and you suffer an injury as a consequence, then you are eligible to make a public liability claim.

Hence in order to make a public liability claim, you will need to prove two things:

  1. Your accident could have been avoided if the owner or occupier took reasonable steps to prevent it; and
  2. You suffered losses as a result of your injury.

Insurer’s obligations:

An insurer is obligated to consider all the information and medical evidence available to them prior to disputing liability for your claim or any part of your claim. This may include considering clinical notes from your treating doctors, any statements submitted by or on behalf you and any independent reports available.

An insurer is required under section 74 of the Workplace Injury and Compensation Act 1998 to provide you a notice of the dispute in writing with a statement explaining why the claim is disputed and providing clear reasoning for their decision.  It is not sufficient for the insurer to decline your claim and inform you over the telephone. You should also receive copies of the medical documents and evidence the insurer has relied upon to reach their decision, if a copy of the documents have not been provided, you have the right to request this from the insurer.

Injured person’s rights:

When you receive a dispute notice, the following two options are available for you to challenge the insurer’s dispute:-

  1. Submit a request for an internal review directly to the insurer; and/or
  1. Make an application to the Personal Injury Commission to hear the dispute and make a determination of the issues.

An insurer that issues a dispute notice often provide instructions to the injured person on how to lodge an internal review. It often requires an injured person to complete an internal review form and submit further evidence to convince the insurer to alter their decision. Internal reviews are assessed by a claims assessor other than the assessor who initially issued the dispute notice.

Insurers are required to assess internal reviews and provide a decision within 14 days from the date the request has been submitted. It is rare for an insurer to overturn their decision after receiving a request for an internal review. In fact, this provides the insurer an opportunity to amend the mistakes they may have previously made and strengthen their reasons to decline your claim.

When an injured person receives a notice of dispute from an insurer, it is always better to seek legal advice from an accredited specialist in personal injury to find out if an application can be lodged in the Personal Injury Commission. A personal injury lawyer will review the insurer’s decision and will assess the merit of your claim.  If they believe the insurer’s decision is unreasonable or incorrect, they will advise you to lodge an application to the Personal Injury Commission.

This process normally takes 3-4 month, as it will require your lawyers to request a copy of your file from the insurer, to gather medical evidence from your treating doctors, obtain an independent medical report and prepare a statement on your behalf before lodging the dispute with the Personal Injury Commission. Preparation stages are not taken lightly by lawyers as this stage will either make or break your claim. Therefore, it is significantly important that each issue raised by the insurer in their notice of dispute is addressed and there is evidence to support it.

The following steps are then taken by your lawyer to file your claim in the Personal Injury Commission: –

  1. Lodging an Application to Resolve a Dispute, together with all of the evidence upon which you tend to rely.
  1. The application with the commission seal is then served to the insurer to notify them that the commission is involved and will determine the issues in dispute.
  1. The insurer is then required to lodge and serve a Reply within 28 days, together with the evidence upon which they tend to rely.
  1. Concurrently, the commission lists the claim for a Telephone conference in an attempt to provide the parties an opportunity to discuss the issues in dispute and reach a resolution. A teleconference often follows four (4) weeks after an application is made by the injured worker to have their matter determined by the commission.
  1. You must attend the telephone conference which is arranged by the commission. However, your lawyers will address the commission during the telephone conference and will argue your case against the insurer.
  2. If the parties do not reach an agreement at the teleconference, the appointed member will then require the parties to attend the commission for a face to face conciliation conference/Arbitration hearing in four (4) weeks from the date of the telephone conference. At the conciliation conference, the parties are once again provided an opportunity to discuss the issues and reach an agreement. If the parties do not reach an agreement, the conference will proceed to second phase, which is the arbitration hearing. At this stage, the lawyer for each party will submit the orders they want the member to make and provide reasonings in support.
  1. The member will then make a decision in writing within 21 days from the date of the conciliation conference/arbitration hearing which is binding on you and on the insurer.

In one claim from August 2021, we were able to successfully challenge the insurer’s dispute declining our client’s neck surgery. The insurer in this case alleged that our client’s neck injury does not relate to their work-related incident, hence refusing to pay for the expenses related to it. Our team of expert lawyers reviewed the insurer’s dispute notice in depth, gathered relevant evidence from the client’s treating doctors/specialists, obtained multiple independent medical reports and prepared multiple statements on behalf of the client.

The dispute was then filed in the Personal Injury Commission to be determined by a member. At the initial telephone conference, we prevented the insurer from raising legal issues which were not addressed in their dispute notice, and we relied on our extensive evidence to make submissions in support of our client’s claim. However, despite our efforts, the insurer did not come to an agreement to accept liability for our client’s neck injury. Consequently, the dispute was set for a Conciliation Conference/Arbitration Hearing. As a result, the member made a determination in favour of our client and the decision was binding on the insurer. We provided these services to our client on “No win No Fee” basis.

As accredited specialist in Personal Injury lawyers who have been in the business for more than 10 years, we have dealt with numerous types of legal disputes and have achieved results for our clients, which seemed impossible at the outset of their claim. Our team of lawyers are experts with many years of experience in winning workers compensation disputes and can provide you with the advice you need to successfully overcome the rejections in your claim and receive compensation.

If you have suddenly received a dispute notice from the insurer, Alliance Compensation Lawyers are here to help. Attend a no obligation consultation with us and receive the advice you need.

Call us on 02 8764 1776 or request a free call.

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