What Should I Do if My WorkCover Claim Has Been Denied?

Last updated on January 17th, 2024 at 12:34 pm

You’re at work, doing your usual tasks, when an unexpected accident happens. Maybe it’s a slip on a wet floor or an injury while lifting something heavy. Regardless, you do the right thing: report the incident, seek medical help, and file a WorkCover claim to support your recovery and compensate for lost wages. 

But then, a setback: your claim is denied, with reasons that are either unclear or suggest the injury wasn’t work-related. Now, you’re not just dealing with physical pain but also the stress of mounting bills and the uncertainty of what to do next. It’s a tough spot, one that too many employees unfortunately find themselves in. Here’s how to turn things around.

Steps to Take if Your WorkCover Claim is Denied

1. Understand the Denial

Start by reading the denial letter carefully. The reasons for the denial will guide your next steps. It’s important to understand exactly why your claim was rejected.

2. Gather More Evidence

Depending on why your claim was denied, collect additional evidence to support your case. This could include detailed medical reports, statements from witnesses, or proof that your injury is work-related.

3. Consult Your Doctor

Talk to your healthcare provider to clarify any medical questions about your claim. Make sure your medical records accurately reflect your injury and its impact on your work.

4. Get Legal Advice

Reach out to a WorkCover lawyer for advice on how to proceed. They can help you understand the strength of your case and the best way to appeal the denial.

5. File an Appeal

If the denial seems unjust, file an appeal promptly, adhering to the deadlines in your policy. Your lawyer can assist in preparing and submitting the necessary documents.

6. Prepare for the Review Process

The appeal might involve an insurance company review or a workers’ compensation board hearing. Be ready to present your case, with your lawyer’s help if you have one.

7. Stay Organised

Keep detailed records of everything related to your injury: correspondence, medical treatments, and expenses. This organisation is crucial for a smooth appeal process.

8. Keep Communication with Your Employer

Keep them updated, especially if the appeal affects your return to work or requires their input.

9. Know Your Rights and Responsibilities

Understand what you’re entitled to under the WorkCover system and your responsibilities, like following treatment plans and attending meetings or hearings.

10. Explore Alternative Solutions

If the appeal doesn’t go your way, talk to your lawyer about other compensation forms or dispute resolution methods.

Common Reasons for WorkCover Claim Denial and Solutions

Insufficient Evidence of Injury

One of the primary reasons for a claim denial is the lack of sufficient medical evidence to support the injury claim. This includes inadequate documentation of the injury’s extent, its impact on your work capacity, or its direct connection to your workplace activities.

Solution: If there’s not enough medical evidence, get detailed reports from your doctor. Make sure these reports detail the extent of your injury, its impact on your work capacity, and its direct connection to your workplace. 

Disputes Over Work-Related Injuries

Insurers often deny claims if there’s a dispute about whether the injury occurred during employment. This might happen if the injury occurred off-site, during a break, or when the link to work activities is unclear.

Solution: Provide clear and detailed evidence that the injury occurred during employment. This can include time-stamped security footage, eyewitness accounts, or documentation of your work activities at the time of the injury.

Late Reporting or Claim Submission

Timeliness is critical in WorkCover claims. Delay in reporting the injury to your employer or filing the claim can lead to denials, as insurers may question the validity or severity of the injury due to the delay.

Solution: Report any workplace injury to your employer immediately and file your WorkCover claim immediately. Keep a record of when you reported the injury and any correspondence related to it.

Pre-Existing Conditions

If you have a pre-existing medical condition, insurers might argue that your current injury is related to that condition rather than a new workplace incident. This is especially common with musculoskeletal and repetitive strain injuries.

Solution: Show that your current injury is separate from any previous conditions. Medical reports that differentiate between pre-existing conditions and new injuries can be crucial.

Inconsistencies in Documentation

Any inconsistencies in your accident report, medical records, or witness statements can raise red flags for insurers. This includes discrepancies in how the injury occurred or its severity.

Solution: Review and ensure consistency across all documentation, including your accident report, medical records, and witness statements. Correct any discrepancies and provide supplementary evidence if necessary.

Non-compliance with Treatment Plans

If you fail to follow prescribed medical treatments or miss medical appointments, insurers might doubt the seriousness of your injury or question your commitment to recovery, leading to claim denial.

Solution: Follow all medical advice and treatment plans diligently. Keep records of all your appointments, treatments, and any related communications to demonstrate your commitment to recovery.

Failure to Meet Policy Criteria

Every WorkCover policy has specific criteria and definitions regarding what constitutes a compensable injury. Your claim may be denied if your injury doesn’t meet these criteria.

Solution: Familiarise yourself with the specific criteria of your WorkCover policy. If your injury does not initially meet these criteria, consult with a legal expert to explore possible interpretations or additional evidence that could support your claim.

Conclusion

Remember, being proactive and informed can significantly improve your chances of a successful WorkCover claim. For expert legal advice, Seymour Furlong Lawyers are here to help. We specialise in these cases and can guide you through TPD claims, too. Contact us at 07 3879 1644 or 0450 486 862 or via email at peter@seymourfurlong.com.au for a free consultation. We’re committed to helping you get the compensation you deserve.