If your workers’ compensation claim is rejected in WA, the insurer issues a notice explaining its reasons, and no compensation is paid while that decision stands. The decision is not necessarily final. You can ask for it to be reviewed and, if the dispute is not resolved, apply to the Workers Compensation Conciliation Service at WorkCover WA. A workers compensation lawyer Perth can explain your options and help you respond.
Receiving a notice that your claim has been disputed can be worrying, especially when you are injured, off work and relying on payments to cover your bills. Many workers do not realise that insurers must follow set timeframes and give reasons for their decisions, or that there is a formal process to challenge them. In this article, we explain how insurers decide claims, the common reasons for rejection, how to respond to a decision, how conciliation and arbitration work and how to strengthen your claim
Key Takeaways
- A rejection is not the end of the road, as you can ask the insurer to reconsider and, if necessary, apply to the Workers Compensation Conciliation Service at WorkCover WA.
- An insurer has 14 days to respond to your claim, and if it stays silent, the claim is treated as accepted.
- Go through the decision notice carefully and ask for copies of the reports the insurer relied on.
- WorkCover WA’s conciliation and arbitration services can settle the dispute without a court hearing.
- Solid evidence, gathered and presented promptly, gives you a better chance of a fair outcome.
How Insurers Decide on Your Claim
Under WA’s Workers Compensation and Injury Management Act 2023, the insurer of your employer is required to act on your claim within certain periods. It is expected that the insurance company provides you with either a liability decision notice or a deferred decision notice within 14 days after receiving your claim.
The Act also sets out what happens when these timeframes are missed. If neither notice is issued within 14 days, the claim is taken to have been accepted. Where a decision is deferred, provisional payments may begin after 28 days, and if no final decision is made within 120 days of receiving the claim, it is also taken to have been accepted.
Common Reasons a Claim Is Rejected
Insurers dispute claims for a range of reasons, and some of the most common grounds include:
- The insurer believes the injury did not arise from your work
- There is limited medical evidence linking your condition to your duties
- The injury is said to relate to an existing condition rather than your job
- The insurer questions whether you are a worker rather than a contractor
- For psychological injuries, the insurer argues the condition resulted wholly or predominantly from administrative action that was not unreasonable and harsh, such as a performance appraisal or disciplinary action.
A rejection on one of these grounds does not necessarily mean the decision will stand, as many disputes turn on the strength of the evidence, which can often be improved.
Understanding the Workers Compensation Claim Rejection Process in WA
A rejected claim is usually handled in stages. These steps show how the process generally works for injured workers in WA.
Read the Liability Decision Notice
The notice should explain why the insurer disputed your claim. Read it closely and keep a copy.
Get Copies of Relevant Reports
Ask for all the medical or investigation reports that the insurance company relied on while making the decision.
Tackle All Possible Causes of Rejection
Deal with the problems as mentioned in the letter by presenting new information to solve the problems raised by the insurance company.
Request a Formal Review
Present the new information and request a review of the decision under the insurer’s internal dispute resolution process. This is not a required step before applying for conciliation.
Lodge an Application With WorkCover WA
If the dispute is not resolved, you can apply to the Workers Compensation Conciliation Service at WorkCover WA for assistance.
Resolving a Workers Compensation Dispute WA Through Conciliation and Arbitration
WorkCover WA’s Workers Compensation Conciliation Service and Workers Compensation Arbitration Service provide independent dispute resolution services to help workers, employers and insurers resolve disagreements without going to court, and the process generally has two stages.
The first step is conciliation, wherein a conciliator meets with the parties involved, assists them in identifying the issues in dispute, and works out an agreement on their differences. This dispute can be settled at this level itself, and conciliation is a less formal process than a hearing.
Where the issue fails to be settled through conciliation, arbitration could take place. Arbitration involves an arbitrator evaluating all the facts and claims brought forward by each party and then arriving at a decision. An appeal to the District Court requires the Court’s leave and generally involves a question of law, so preparing your case properly from the start is important.
Strengthening Your Workers Compensation Claim Perth After a Rejection
If your claim is heading to review or conciliation, these practical steps can help you build a stronger case:
- Asking your treating doctor for a detailed report explaining how your work caused or contributed to your injury
- Seeking a specialist opinion where your condition is complex or disputed
- Writing a clear timeline of how and when the injury occurred and when you reported it
- Gathering statements from coworkers who saw the incident or know about the working conditions involved
- Keeping copies of all correspondence, certificates of capacity and medical records
- Continuing with recommended treatment and taking part in injury management
Conclusion
Having a claim disputed is more common than many workers expect, and WA law provides a process to challenge the decision through conciliation and where necessary, arbitration. Understanding why the insurer disputed your claim, responding with the right evidence and using the conciliation and arbitration process can all improve your chances of a fair result. Prompt action is also advisable because it becomes easy to collect evidence when incidents are still fresh.
At MPK Lawyers, we represent injured workers throughout Perth who are having issues with their claims being challenged by insurance companies. In cases where your claim has been denied, consulting with an experienced workers compensation lawyer Perth will help you find the right course of action.
Frequently Asked Questions
1. Can I challenge a rejected workers compensation claim in WA?
You can. Most challenges begin with a request for the insurer to reconsider. If that does not resolve the issue, an independent conciliator and, if needed, an arbitrator can decide the dispute.
2. How long does the insurer have to decide on my claim?
Insurers generally have 14 days to accept, dispute or defer your claim. A deferred claim must then be finally decided within 120 days, or it is treated as accepted.
3. Will I receive payments while my claim is being decided?
If the insurer defers its decision and has not given a liability decision notice within 28 days after receiving the claim, provisional payments for income compensation and medical and health expenses become payable, subject to the statutory scheme.
4. Why are psychological injury claims often disputed?
Insurers may argue that the condition resulted wholly or predominantly from administrative action that was not unreasonable and harsh, such as performance appraisal, suspension or disciplinary action. Whether that exclusion applies depends on the facts, including the action taken and how it was carried out.
5. Do I need a lawyer to dispute a rejected claim?
It is not required, but a workers compensation lawyer Perth can review the insurer’s reasons, gather supporting medical evidence and represent you through conciliation and arbitration, which often makes the process easier.
Get Help With Your Disputed Claim
Book a free consultation to talk through your rejected workers’ compensation claim in Perth and find out what options may be available.