Workers Compensation Claims

> Introduction
> Eligibility to make a claim
> New procedures for claims
> Time frames
> Common law claims
> Templates & References
 

Introduction

Making a claim for workers compensation has been simplified.  The worker notifies you of an injury, and your notification to the insurer begins the process of provisional payment to the worker.  This gives the worker an income while the insurer gathers the facts to support or dispute a claim. Further benefits are paid to the worker if the claim is accepted.  Sometimes a claim form is required, especially if the worker is claiming for permanent injury or if the insurer requests.

Eligibility to make a claim

To be eligible to make a claim a person:

• must be a "worker" or a "deemed worker"; 
• must have suffered a personal injury or illness arising out of or in the course of employment;
• must show that employment was a substantial contributing factor to the injury or illness; and
• must be covered by the New South Wales workers compensation legislation.

New procedures for claims

In most cases, an injured worker does not need to fill in a claim form to receive workers compensation. Once you notify the insurer that a worker has sustained an injury at your organisation, the insurer must start payments within seven days.  They must then investigate the facts to either confirm or deny subsequent payments. Most of the information that the insurer needs to make a decision about workers compensation will already be available from you, the worker, and the treating doctor.

Provisional payments are not an admission of liability by either you or your insurance company. However, your insurer must not unreasonably delay payments or it risks a fine of up to $5500.

There is, however, some times where a worker will need to make a written claim for workers compensation:

• if the insurer asks the worker to make one;
• if the worker needs more than provisional liability payments (that is weekly payments for more than 12 weeks or medical expenses of more than $5,000);
• if the insurer has stopped making provisional payments and the worker disagrees.

Time frames

• A worker is not entitled to compensation unless notice of the injury has been given to the organisation as soon as possible after the injury happened and before the worker has voluntarily left your employment.
• A worker who wants to make a claim for workers compensation should do so within six months of the date of injury. In special circumstances, eg diseases which may take some time to develop, this can be extended to three years.
• Provisional liability payments must be paid to the injured worker within seven days of the insurance company being informed that an injury has occurred, unless there is a reasonable excuse to not start payments.
• If a claim form has been filled in by the worker and sent to the insurer or your organisation, the insurer has 21 days to make a decision to accept or dispute the claim.
• In some cases provisional weekly payments would have already commenced. The insurer would have informed you and the worker of the number of weeks or days for which provisional payments are approved. In these cases the time frame that the insurer has to make a decision on the claim may be extended to the end of the period approved for the provisional payments.

Common law claims

A common law claim is when an injured worker sues your organisation for damages. There are three criteria that must be met:

1. The injury has to be caused by the organisation’s negligence or that of a fellow worker. Negligence is a failure to take reasonable care of the worker.
2. The injured worker must have sustained a permanent injury that is at least 15% whole person impairment.
3. A common law claim for damages cannot be started for at least 6 months after the worker gave notice of the injury to the employer or three years after the date of injury.

Common law claims are mediated in the Workers Compensation Commission before proceeding to the District or Supreme Courts depending on the amount claimed. Damages are paid as one lump sum to cover past and expected future economic loss. They can be reduced if the worker's own negligence contributed to their own injury.

Templates & References

Contractor agreement template

WorkCover Medical Certificate