How does an injured worker claim workers compensation?
Before making a claim, the injured worker or their representative must advise the employer that an injury has occurred, and provide medical information. An injured worker does not, in most cases, need to send a written claim form to the insurer to receive workers compensation. Instead, once the insurer has been told of an injury (by the employer, the worker or a third party), the following will occur:
- provisional liability payments will start within seven days (for most injured workers)
- the insurer will investigate the facts and decide to either continue or stop further payments. Most of the information that the insurer needs to make a decision about workers compensation will be available from the employer, the worker and the treating doctor.
There are occasions, however, when a worker will need to submit a written claim form, such as:
- if the insurer requests one (eg. if the insurer is notified two months after the injury)
- if the worker needs weekly payments for more than 12 weeks or medical expenses of more than $7,500
- if the insurer decides to not start provisional liability payments, or stops making provisional liability payments, and the worker disagrees.
How does the insurer decide whether to accept the claim?
Before provisional liability payments begin or a claim is accepted, the insurer requires certain facts. It will investigate the matter by questioning the employer and the worker, and seeking information from the treating doctor.
Under the Worker’s Compensation Act 1987, a person is only entitled to workers compensation if:
- the person is a ’worker ‘or a ’deemed‘ worker
- the injury is work-related
- the work was a substantial contributing factor to the injury
- the person is covered by NSW workers compensation legislation.
How soon must the insurer make a decision on the claim?
Within seven days of being informed – verbally, electronically, by claim form, etc – that an injury has occurred, the insurer must begin provisional liability payments to the injured worker, unless there is a reasonable excuse to not start payments. The Insurer must also decide how long provisional liability payments will continue, up to a maximum of 12 weeks.
If, following the initial notification of injury and commencement of provisional liability payments, a claim form is submitted (after, say, four weeks), the insurer has either 21 days, or until the period of provisional liability expires, to make a decision. Based on the type of injury and incapacity, the insurer may decide to extend provisional liability for a further four weeks.
Is there a time limit for making a workers compensation claim?
A claim for workers compensation should be made within six months of the date of the injury. In special circumstances this can be extended to three years.
A worker is not entitled to compensation unless notice of the injury has been given to the employer as soon as possible after the injury, and before the worker has voluntarily left the employment in which the worker was at the time of the injury.
Permanent Impairment
A worker who has received an injury that results in permanent impairment may be entitled to receive lump sum compensation payments in addition to weekly benefits.
Agreements for lump sum payments for permanent impairment and pain and suffering require the insurer to be satisfied that the worker has obtained independent legal advice prior to accepting payment. The insurer is required to record evidence that this advice has been obtained and the details of the agreement.
An injured worker who has agreed to a lump sum payment for permanent impairment is not entitle to recieve additional compensation unless there has been an increase in the degree of permanent impairment that occurred after the payment was made.
Enquiries on previous lump sum payments for permanent impairment can be made with WorkCover, you can email us with your enquiry.