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      What should I do if my workers compensation claim is denied?

      Quick answer

      Your insurer must send you a letter outlining the reasons they denied your workers compensation claim. You can challenge this decision. In most states, you will be required to first participate in a mediated negotiation with your insurer. Your claim will only proceed to court if these negotiations fail.

      Overturning insurer decisions is a complex process and requires a skilled understanding of workers compensation law. An experienced lawyer will handle negotiations on your behalf and ensure you receive a fair outcome.

      For information on challenging denied claims in NSW and Queensland, see our comprehensive guide below.

      In depth answer

      Your insurer may deny your claim for many reasons. The most common reasons are:

      • You are not a ‘worker’ under your state legislation.
      • Employment was not a substantial contributing factor to your injury.
      • It was not ‘reasonably necessary’ to have medical treatment or other claim-related expenses.
      • Your injury happened outside of work.
      • Your injury is pre-existing.
      • Your claim was made outside your state’s time limit.
      • Your employer disputes your account of the injury.

      You are entitled to challenge a denied workers compensation claim. How you do so depends on the state you’re claiming in.

      We suggest speaking to an expert lawyer before challenging a denied claim. Insurers are well-resourced and denied claims are notoriously complex. It can be difficult to have your denied claim overturned without a workers compensation specialist.

      Different laws apply in different states. Please choose your state below so we can show you the most relevant content.

      Your insurer must outline their reasons for denying your claim in a written ‘section 78’ decision notice.

      How do I challenge my denied claim?

      Your first step is to request a review from your insurer. Your insurer should provide a review form.

      We suggest speaking to a lawyer at this point. They will explain the dispute notice and help you request a review. Your lawyer will also gather evidence to support your case and guide you through the next steps. What those steps entail changes from case to case. They will depend on both the nature of the dispute and the reasons your insurer rejects your claim.

      After you have requested a review and taken all the necessary steps, your insurer will respond. The response must be in writing and within 14 days of receiving your request. You may be required to make further submissions, be examined by your insurer’s doctor, or provide further medical evidence.

      In the end, your insurer will either overturn or modify their original decision, or maintain it. There are still options available even if your review is rejected. Our Workers Compensation team have decades of experience overturning denied claims.

      Your insurer must provide a letter explaining why your claim was denied. WorkCover Queensland representatives may also call to discuss your denied claim.

      How do I challenge my denied claim?

      You have 3 months to lodge your review application with the Office of Industrial Relations. Your review will be undertaken by a Review Officer working with the Workers Compensation Regulator.

      The Review Officer will re-examine your claim. They do not re-investigate your application and will never request further information.

      It’s important to know that certain insurer decisions cannot be reviewed. You must instead appeal the decision directly to the Queensland Industrial Relations Commission (QIRC). These include decisions:

      • Not to fund a particular medical procedure
      • Regarding the ongoing management of the application for compensation
      • Not to apply the premium discount.

      If you are unhappy with the result you can challenge the review. This results in a second review where the results are final. If you wish to challenge the decision again, you must appeal to the QIRC within 20 business days.

      An appeal to the QIRC requires both you and the insurer to make submissions to the Court. We suggest engaging an experienced lawyer before starting your appeal. Our team are Workers Compensation specialists and have successfully overturned hundreds of insurer decisions.

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