Liability decision types

The decisions made on your claim will be informed by the information available at the time and in consultation with yourself and the worker.

Once your worker's claim has been lodged and your case manager has made contact with both yourself and your worker, an important process plays out—the decision about whether the injury is covered under workers compensation law. Your case manager is the person who will make this decision and they do so based on information they've gathered from you, your injured worker, their doctor and other key stakeholders like their treating psychologist.

There are a number of different types of liability decision. You won't experience all of them, but we'll explain each one here, because each claim journey is different.

On this page

Interim liability decisions

Formal liability decisions

Timeframes

Interim liability decisions

First of all, an initial liability decision needs to be made within the first seven days of the claim being lodged. This first decision is important, because it enables your worker to start accessing the things they need, like treatment, weekly wage benefits and medication. Often, your case manager will make what's called an interim decision. When they do this, it's because they need more time to gather the information they need to make a soundly based formal liability decision.

If your case manager has enough information, they can make a formal liability decision up front as the first liability decision. If they do, the formal decision will be either to accept or decline liability for the claim. Whichever decision is made, you'll receive a notice that explains what the decision was and why it was made. You'll also find information on how to have the decision reviewed if you disagree with it.

If your case manager needs more information before they can make a formal liability decision, they'll make an interim decision first. These are the different interim decisions that can be made:

Provisional liability

Provisional payments allow your case manager to start making payments including weekly benefits, before they make a formal liability decision. A decision to commence provisional payments is not a decision about liability. The provisional period can extend up to twelve weeks of weekly payments or up to $10,000 in medical and related expenses from the date the claim is notified.

In this time, you case manager will be undertaking investigations to understand more about your worker's injury and how it happened. They'll then use this information to make a formal liability decision.

Learn more about provisional liability

Reasonable excuse

A reasonable excuse is a reason for insurers to not commence provisional weekly payments.

While a reasonable excuse exists, your worker is still entitled to receive compensation for reasonably necessary medical and related expenses up to $10,000. Your case manager must use this time to take urgent and appropriate action to investigate their claim. A reasonable excuse should not be applied for any longer than is necessary.

Learn more about reasonable excuse

Formal liability decisions

Your case manager is obliged to make a formal liability decision before the end of the provisional liability period. When a reasonable excuse no longer remains appropriate (has been resolved), your case manager can either provisionally accept the claim or make a formal decision on liability. This formal decision is the gateway to your worker's ongoing access to benefits under the claim.

If the claim is accepted, your worker is entitled to receive weekly benefits (if their injury results in lost wages), cover for medical expenses and treatment and a range of other supporting benefits enabled under worker compensation legislation.

If liability for the claim is declined, your worker is not entitled to receive any benefits under the claim. Before benefits cease, certain notice periods may apply depending on how many weeks of weekly payments they've received. If you disagree with a decision to approve or decline liability, you are entitled to have that decision reviewed by someone independent of the initial decision process.

Formal liability decisions tend to occur in the early stages of the claim, when provisional liability has expired or right up front. There are some limited circumstances where liability decisions occur later in the life of the claim:

• if the injury occurred as the aggravation of an underlying condition they were already experiencing and that aggravation has ceased
• if a new injury is introduced
• if new treatment is requested
• when they lodge a claim for a lump sum if they're assessed to have a permanent impairment
• when they lodge a claim for work injury damages.

Timeframes

In the early part of a workers compensation claim, everything is about timeframes. Here's a reminder about the key timeframes:

• Seven days: Your case manager has seven days to make an initial liability decision
• 21 days: If your worker submitted a completed claim form with the certificate of capacity from their doctor, your case manager has 21 days to make a formal liability decision. If the claim was previously placed under a reasonable excuse, your case manager can also provisionally accept your claim within the 21 days
• 12 weeks: Provisional liability extends for a maximum 12 weeks of weekly payments. Your case manager must make a formal liability decision on or before the day 12 weeks expires, or when medical and related expenses reach $10,000 on the claim.