A Workers Compensation Claim is vital to supporting a worker while they are recovering from a workplace injury or illness, however, sometimes without sufficient evidence or due to evidence found by the insurer the claim can be rejected. If your Workers Compensation Claim has been rejected here is an outline of how this can happen, why the insurer might have chosen to do so and what you can do to dispute the decision.
In most instances, if you need help with a dispute against the insurer, we can obtain funding from IRO (Independent Review Office) for your legal costs. If funding is granted, IRO will pay for your legal costs.
How can an insurer reject a Workers Compensation Claim?
The practice around workers compensation is very well regulated in New South Wales, which means that there are strict rules around how things need to be done to ensure that workers are treated fairly. In the case of denying a Workers Compensation Claim, an insurer must send the injured worker a Section 74 Notice to inform them of the decision to reject their claim.
A Section 74 Notice is a decision to dispute liability and is usually given out if the insurer believes they have sufficient evidence to prove that they should not be responsible for paying the claim. A Section 74 Notice must include the following:
- A clear statement outlining why the insurer disputes liability.
- An outline of all the documentation submitted by the claimant.
- An outline of all the documentation and evidence obtained by the insurer.
- A copy of all reports obtained by the insurer relevant to the claim and rejection of the claim.
If the insurer issues a Section 74 Notice they must give the claimant notice before terminating payment, 2 weeks notice if the claimant has been receiving compensation for less than a year and 6 weeks if they have been receiving for more than a year.
What are common reasons for an insurer to decline a Workers Compensation Claim?
Reasons to dispute liability can vary significantly and can often be challenged by a competent lawyer if there isn’t sufficient evidence behind it or the reason is not viable as a reason to dispute liability. Some common reasons for disputing liability include:
- The injury or illness was not sustained due to circumstances related to work
- The psychological injury was caused by the reasonable action of the employer
- The inability to work is not due to the injury sustained at work
- The inability to work is due to a pre-existing illness or injury
- The treatment requested is not reasonably necessary.
What to do if your Workers Compensation Claim is rejected?
While most insurers will not send out a Section 74 Notice lightly, if the worker has a legitimate claim to the compensation then a good lawyer can help review the rejection and outline how it might be disputed. To dispute a Section 74 Notice a lawyer has two options:
- Request an internal review from the insurer
- Lodge an application with the Workers Compensation Commission of NSW
Most lawyers will prefer to go straight to the Workers Compensation Commission in order to dispute the rejection. This is because once the Section 74 Notice is challenged with the Workers Compensation Commission the insurer will not be allowed to raise any issue other than those that were outlined in the notice. This is different to an internal review where the insurer can continue to gather more evidence and make a stronger case to dispute the claim.
Once your lawyer lodges an Application for Dispute with the WCC, the commission will appoint an independent arbitrator to hear and determine the issues in the dispute. The decision of the WCC is final and binding for both you and the insurer, unless the Arbitrator has made an error of law.