Claim process

The claims process:

• The worker must give notice of injury as soon as possible after the injury preferably in writing but it can be verbal.
• The worker should consult a medical practitioner and obtain a WorkCover medical certificate and if a significant injury, nominate a medical practitioner to undertake the role of nominated treating doctor.
• You must notify your insurer within 48 hours of first becoming aware of an injury.  The initial notification can be done by the injured worker or their representative or by the employer or their representative.  Notification can be done electronically, in writing or verbally (including over the phone).
• The insurer(scheme agent) must authorise provisional payments unless there is a ‘reasonable excuse’ within 7 days of receiving the initial notification.  This is without admitting liability and enables immediate payment of lost wages and medical expenses.  Provisional liability exists for a maximum of 12 weeks and maximum of $7500 for medical expenses.  Reasonable excuses for not commencing provisional payments include:
  • Insufficient medical information
  • Injured person is unlikely to be a ‘worker’
  • Insurer is unable to contact the worker
  • The worker refuses access to information
  • Firm evidence that the injury is not work related
  • Injury is not significant (insurer may extend time to assess entitlements to 21 days)
  • Notice of injury is not given to the employer within two months after the date of injury (insurer may ignore this excuse if a liability is likely to exist).
• The insurer may request a claim form if the worker requires benefits that exceed that available under provisional liability.  The completed claim form may be given to the employer or the insurer.  The employer must forward the claim form and any other documents to the insurer within seven days of receiving them.  Additional documents include WorkCover medical certificates and receipts for services.
• The insurer must generally determine if they are to accept liability for the claim within 21 days of the claim being made except where making provisional payments or if the claim is for lump sum permanent impairment.

It is important to note that a claim for compensation benefits must be made within six months of when the injury occurred, or within six months of when the worker first became aware of their injury and no compensation benefits are payable if a claim is not made within three years of the injury or when the worker first became aware of their injury, unless the injury results in death or serious and permanent disablement.  However, if the injury is recorded in a register of injuries within six months of the injury the time limit provisions do not apply.

The insurer is required to prepare an injury management plan in consultation with the doctor, employer and worker for significant injuries (more than 7 days absence from pre-injury duties) and to monitor and review that plan.

See attached flowchart for a summary of the above.