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WorkCover Claims Assessment in Victoria

WorkSafe Agents, also called WorkCover Insurers, have 28 calendar days to respond to your claim from the date they’ve received the documents from your employer. An exception to this is 3 business days from the date of provisional payments for a mental injury claim. During that period, the insurer may also refer you to an independent medical examination and may contact you to discuss your claim in further detail. 

Once your claim has been investigated, you and your employer will be advised in writing whether has been accepted or not.

Your role while the WorkCover Insurer assesses your claim

Regardless of who was responsible for the injury, your employer is required to help you design a rehabilitation and return to work plan. Your employer must also make reasonable steps to foster a safer work environment for you and put you on light duties in accordance with the medical advice provided to you in your Certificates of Capacity. You must take all reasonable steps to participate in rehabilitation and to return to work. If you do not make reasonable attempts to return to work, your benefits can be stopped.

Tip

If your employer makes suggestions as to what light duties you might be able to do, or a return to work plan, ask them to put it in writing, and take the plan to your GP.

Tip

Do not let a WorkCover insurer, or their appointed rehabilitation provider, attend an appointment you have with your GP. You should always be able to consult your GP without any influence from the WorkCover insurer.

What happens when your claim gets accepted

The WorkCover Insurer will notify you and your employer in writing that your claim has been accepted and will provide you with further information regarding calculating your pre-injury average weekly earnings (PIAWE), and your employer must start paying you on your usual days within 7 calendar days of WorkSafe Agent accepting your claim. 

Unless WorkSafe notifies your employer otherwise, they must continue paying you for as long as you provide valid Certificates of Capacity, even if you have resigned from your workplace.

Entitlements for Medical Expenses

In the initial stages of your claim, you can claim all medical expenses related to your work injury as long as they are reasonable and necessary.

You can choose who provides services to you. The WorkCover Insurer is required to reimburse you for all reasonable medical and like expenses. This reimbursement can sometimes be less than what you have spent on a service. You should contact one of our personal injury lawyers if you are not paid a claimed medical expense.

You can also claim for travel expenses when you see your own treating doctors, allied health professionals and when you are sent to doctors by WorkCover.

You may also claim for home help, help in the garden or for modifications to your home and car, where necessary. You should discuss these needs with your doctor, who can provide a letter to the insurer setting out your needs.

What to do if your WorkCover Claim gets rejected

If your WorkCover claim gets rejected, the first thing to remember is not to get disheartened, as it’s not the end of a case. Many ultimately successful WorkCover claims get rejected at first. You may appeal the decision by lodging a referral to the Accident Compensation Conciliation Service (ACCS), opening up an investigation process, and presenting evidence as to why your claim should be overturned. 

Claims can be rejected for a number of reasons, but a common one usually refers to when an injury or condition doesn’t relate to that injured workers’ duties. 

If you believe your claim has been unfairly rejected, you then have a 60 days to dispute your appeal in Victoria. You should obtain advice from one of our personal injury lawyers as soon as possible after you become aware of the rejection.

Note

Your employer is obligated to commence the return to work schedule before your claim is accepted or rejected. In the event your claim is rejected, your employee is no longer required to meet the return to work obligations unless there is a subsequent conciliation or court outcome that overturns that.

Special Circumstances

If the worker is entitled to provisional payments for a mental injury claim, WorkSafe Agents can continue to pay reasonable costs for the injured workers' mental treatment for up to 13 weeks after the claim was rejected.

What happens if the initial dispute resolution process doesn't work?

Throughout the dispute resolution process, there are several formal resolution procedures. At some point, you may be referred to independent medical specialists,known as the Medical Panel, where they will review your case and your injury history and decide whether your case should have been accepted.

There are also circumstances where the decision of the WorkCover Insurer is referred to the Magistrates’ Court of Victoria, where a Magistrate will decide as to whether your claim should have been accepted.

Continue reading next...

Understanding WorkCover Claims (VIC)

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