What Happens If A Workers Compensation Claim Is Declined?

Why Do Workers Compensation Claims Get Denied?

NSW Workers Compensation claims can be denied for several reasons, including:

• Insufficient evidence: Lack of medical reports, witness statements, or other documentation.
• Claim outside the time limit: Failure to notify your employer or insurer within the required timeframe.
• Dispute over the cause of injury: Your employer or insurer may challenge whether the injury occurred at work.
• Pre-existing condition: A pre-existing health issue might be claimed as the cause of the problem.
• Fraudulent claims: Providing false or misleading information can lead to claim denial.

Understanding the reasons for denial can help you build a stronger case if you need to appeal.

What is the Workers Compensation Claim Process?

1. Your lawyer files an Application for Dispute resolution with the PIC which includes all evidence to be relied upon.

2. The Insurer or its lawyer must file a Reply with their evidence within 28 days.

3. The matter is reviewed by the PIC and a telephone conference is appointed usually 28 days later.

4. We are notified by the PIC of the date and time of the telephone conference.

5. We will notify you of the details of the telephone conference which you must attend in person at our office or via the telephone.

6. At the telephone conference the Member will discuss the matter and the issues in dispute. The Member will see if the matter can be resolved by agreement. If not the Member will make orders for further preparation of the claim and list the matter for a face to face Conciliation/Arbitration Conference. Your lawyer will do the majority of the talking at the telephone conference.

7. Your lawyer will then confirm in writing the date and time of the Conciliation/Arbitration Conference which is usually 28 days following the telephone conference but must suit everyone’s availability to attend.

8. If further preparation is necessary your lawyer will contact you for further information.

9. The Conciliation/Arbitration Conference has two phases:

• The Conciliation phase is where the Member will discuss the issues and see if the parties can reach agreement, if no agreement can be reached the matter proceeds to;
• The Arbitration phase is where sometimes questions are asked to clear up any unknown matters

10. The Member then makes a written decision within 21 days.

11. The Member decision is final and binding on both you and the insurer unless the Arbitrator has made an error of law.

12. The outcome is confirmed by the PIC within 28 days later.

13. The insurer will then pay the compensation awarded to you. If any amount is payable as a lump sum this is usually paid by way of a cheque in your name sent to us about 6 – 8 weeks later.

What happens when a NSW Workers Compensation claim is rejected?

• Review the decision: Contact your insurer to request a review of their decision. You can provide additional evidence to support your claim.
• Seek independent advice: Consult with a workers’ compensation lawyer or the Independent Review Office (IRO) for guidance.
• Appeal the decision: If you’re dissatisfied with the insurer’s decision after a review, you can apply to the Personal Injury Commission (PIC) to resolve the dispute.

What happens if you can’t return to pre-injury duties?

• Medical treatment: Ongoing care to manage your injury and its effects.
• Wage replacement: Compensation for lost income through weekly payments.
• Vocational rehabilitation: Assistance in finding suitable alternative employment.
• Permanent impairment compensation: A lump sum payment for long-term disability.

If you would like further information, check out our Workers Compensation page or contact us to see how we can help.