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What To Expect When You Have A WorkCover Claim

03 Nov 2017

What to expect when you have a WorkCover claim

1. You’re injured at work, or on your way to or from work.

2. You lodge an application for workers’ compensation with WorkCover.

3. WorkCover will allocate a Customer Representative to the claim.

You will be required to provide WorkCover with details of the injury and the event before they make a decision to accept the claim.  WorkCover will also contact your employer to obtain additional information (such as confirmation of employment and wage details) and to notify them that a claim has been made on their policy.

4. Once WorkCover has obtained sufficient information about the injury to make a decision, they advise you and your employer whether your application for workers’ compensation has been accepted.

5. WorkCover may take up to 20 business days to make a decision.  If WorkCover is unable to make a decision within this time period, they will contact you verbally and in writing to advise why a decision cannot be made.

6. Once your claim is accepted payment of workers’ compensation benefits will commence. If the claim is accepted, the claim will be managed by a customer representative.

7. What is covered by WorkCover?

     • Reasonable and necessary medial and rehabilitation costs as approved by your doctor or treatment provider.

     • Medication and medical supplies essential to recovery.

     • Equipment necessary for recovery (eg wheelchair).  

     • Travel expenses for travel more than 20kms each way (when there is not a registered provider closer).

     • Payment of wages if the worker is deemed unfit for work, or if suitable duties are not available.

8. What is not covered by WorkCover?

     • Unreasonable and unnecessary medical and rehabilitation costs.

     • Treatment such as massage therapy, naturopaths or relaxation therapist.

     • Wages if the worker is deemed fit for work or fit for suitable duties and the worker refuses to participate.

     • Medication or treatment for non-work related injuries.

9. What if my claim is rejected?

If you are unhappy with WorkCover’s decision in relation to rejection of your claim, with respect to payment of weekly compensation or the funding of treatment costs, you may have review and/or appeal rights.  Strict time limits apply to reviews and appeals.

10. How are weekly compensation benefits calculated?

     • WorkCover will calculate your normal weekly earnings (NWE) using weekly earnings from continuous or intermittent earnings for the 12 months prior to the injury.  If you have not been employed for 12 months, then the earnings for the period of employment will be used.

     • The NWE will be used to calculate the weekly compensation rate payable for a claim.

     • For most workers, the weekly compensation rate for the first 26 weeks will be paid at the greater of:-
        - 85% of NWE; or
        - 100% of your industrial instrument.

11. Return to work

If a doctor says that you are fit to return to work in any capacity, then you must cooperate with WorkCover and return to work.  If you are unable to return to your normal duties, WorkCover will develop a suitable duties program to help you stay at, or return to work quickly.  A suitable duties plan takes into account your current work capacity, medical advice and individual circumstances.  Sometimes an employer won’t have suitable duties available and in these cases, WorkCover may find employment for you with a host employer. 

If WorkCover places you in host employment that complies with the suitable duties plan, you are obliged to participate in the host employment program.  You must adhere to the host employer’s policies and procedures such as punctuality.  You must also attend and undertake work tasks specified in the program.

At the end of the host employment placement, the host employer is not under any obligation to employ you on a permanent basis.

12. What are your responsibilities while you’re on WorkCover?

     • Cooperate with WorkCover, the employer and doctors.

     • Complete and sign all necessary forms.

     • Let WorkCover know of any changes to your conditions or treatment.

     • Provide WorkCover with all current medical certificates.

     • Ensure that all information provided to WorkCover is true and not misleading.  For example, inform WorkCover if you are recieving Centrelink payments.

     • Participate in rehabilitation programs.

     • Tell WorkCover if you have returned to work of any kind.  This includes self-employment or working for another person.  This applies whether or not you are paid for performing the work.

Penalties may apply for failure to comply with the requirements while on WorkCover.  Compensation benefits may be suspended or you may be prosecuted for serious breaches of your obligations.

13. When does a WorkCover claim come to an end?

When your injury is deemed to be stable and stationary, that is when the doctors consider that there is no further treatment that is likely to improve the work-related injury, then WorkCover’s obligation to provide benefits will cease.

WorkCover will close their file if the injury is deemed to be stationary and stable, regardless of whether you are able to return to work or not.

14. Assessment for Permanent Impairment

Once your injury is deemed to be stationary and stable, and WorkCover have closed their file, you are entitled to be assessed for permanent impairment.  Sometimes WorkCover will make arrangements for the impairment assessment, and if not, you can request it.

WorkCover will arrange an assessment with a medical examiner who will then determine whether you have sustained a permanent impairment as a result of the injury that you sustained at work.

After the assessment you will receive a document called a Notice of Assessment.  The Notice of Assessment will set out the degree of permanent impairment and an offer of lump sum compensation.

It is very important that you obtain legal advice before making any decision in relation to the offer of lump sum compensation.

15. Additional information

• WorkCover customer representatives are employed to process claims.  They sometimes perform their role with little regard for the stress that the injury is putting on you and your family. Sometimes they can be rude and demeaning.  Sometimes they can be helpful and supportive.  Customer representatives are not medically trained, however they have the power to terminate weekly benefits, delay responding (or ignore) requests for treatment and send workers to Independent Medical Examinations with doctors of their choice to undermine the opinion of your treating doctors.

• WorkCover will not automatically approve the treatment proposed by your doctor or treatment provider.  This may include physiotherapy, scans, medication or even surgery.  WorkCover can send you for an Independent Medical Examination with a doctor from their own panel for a “second opinion” as to whether the proposed treatment is necessary or whether the injury was even caused by the event at work.  Often it is determined by the WorkCover doctor that the injury or symptoms have been caused by a pre-existing or unrelated condition – even though the worker has never experienced symptoms before!

• Many employers are reluctant to work with injured workers who attempt to return to work on a suitable duties program.  They may not adhere to medical limitations and may force workers to do more than the doctor has allowed.  Employers may go so far as to make plans to terminate a worker’s employment as soon as they can.  They may often provide an injured worker with demeaning “suitable duties” or tell them that there are no suitable duties available at all.  This will depend on the attitude of your employer to your workers’ compensation claim.