If you have been injured in the course of employment you are entitled to workers compensation entitlements which include but are not limited to wages, medical expenses which include domestic and travel expenses and a lump sum payment. However, what happens if the insurer denies liability which in some occasions affects you from receiving the above entitlements?
Can my workers compensation claim be denied?
Yes, either provisionally or formally.
If the insurer has not paid you wages within 7 days from the initial notification of your injury then it will either delay it by sending you a reasonable excuse notice or deny liability. The main reasonable excuses notice we see the insurer provides within 7 days in circumstances when it has provisionally denied liability is due to either insufficient medical information or if you refused to provide the insurer with access to relevant information such as your medical records. We understand that this may be your first experience and may feel uncomfortable disclosing your past medical records however we recommend you contact our workers compensation lawyers for free advice. The last thing you want, especially when it could have been prevented is for your wages entitlement not be paid just because you did not know your entitlements or provide the insurer with information they needed to make a determination. Even if the insurer provides you with a reasonable excuse notice the insurer can still accept liability for medical expenses and pay up to $10,000 in medical expenses before making a formal decision on liability.
This is a notice of a decision, known as a section 78 Notice, being, when the insurer has made a decision denying liability regarding a claim, any aspect of a claim or to discontinue payments of weekly payments of compensation or reduce the amount of compensation. The decision must have been sent to you, being the injured worker and it must be in writing which must include all documents and information the insurer relied upon in forming its opinion.
What does it mean if my workers compensation claim is denied?
The effect of the decision depends on your claim and the specific decision. It could mean your weekly payments and/or medical expenses entitlements will end depending on the decision. For example, the insurer can deny one part of your claim but accept another part of your claim. You are entitled to challenge the decision and we strongly recommend you contact our workers compensation lawyers for free advice on what it means for you and how the decision can be challenged at no cost to you.
What are some examples of how my workers compensation claim can be denied by the insurer?
Some of the examples of how your workers compensation claim can be denied include but are not limited to the insurer being of the opinion that you:
- Are not a worker
- Did not sustain an injury in the course of employment.
- Your injury is not work related.
- Your injury was pre-existing.
- Your incapacity is not work related.
- Your medical expenses are not work related.
- Your psychological injury is related to reasonable actions caused by your employer.
Unfortunately, the insurer on many occasions relies purely on an Independent Medical Examiner’s, that it organised that forms the opinion that your injury is not work related without obtaining the necessary medical information from your treating doctors who may of the opposite opinion. Our workers compensation lawyers ask your treating doctors the questions that need to be asked to support your claim in challenging the insurer’s decision. Our workers compensation lawyers will also have your injuries assessed by a different Independent Medical Examiner who will assess your injuries afresh and comment on the insurer’s organised Independent Medical Examiner’s report.
What is the process involved in challenging the insurer’s denial?
If you receive either a provisional reasonable excuse denial or a s78 Notice denial of liability notice you are entitled to request for a review of the decision or refer the matter to the Personal Injury Commission, which is the independent tribunal for workers compensation disputes. Usually, the matter proceeds to the Personal Injury Commission which after lodging all your supporting documents, makes a determination, unless your matter is resolved between us and the insurer, based on your instructions, prior to the Personal Injury Commission making a determination. We recommend contacting our lawyers for a free claim assessment to give you advice on what it means, our opinion, next steps, time frame and process.
What happens if the insurer’s decision is successfully challenged?
You will be reinstated your entitlements and your wages will be back paid depending on your claim and the decision.
Do I have to pay for legal costs to be represented by a workers compensation lawyer?
Our workers compensation lawyers are approved by the Independent Review Office (IRO) which means that our costs are covered by IRO. You pay no legal costs or disbursements to our workers compensation lawyers. We also do not deduct our legal costs or disbursements from your workers compensation claim.