Liability decision types
Once you've lodged your claim and your case manager has contacted you, an important process plays out—the decision about whether your injury is covered under workers compensation law.
Your case manager is the person who will make this liability decision and they do so based on information they've gathered from you, your employer, your doctor and other key stakeholders, like your treating psychologist.
There are a number of different types of liability decisions. You won't experience all of them, but we explain each one here, because everybody's claim journey is different.
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Initial liability decision
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 you to start accessing the things you need, like treatment, weekly benefits and medication. Often, your case manager will make what's called a provisional decision. When they do this, it's because they need more time to gather the information that they need to make a formal liability decision.
Tip: When we count the number of days a case manager has to do something, the day the claim is received is referred to as day zero. The next day is day one, and so on as the claim progresses.
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 your 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 initial liability 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.
The provisional period can extend up to 12 weeks of weekly payments or up to $10,000 in medical and related expenses. In this time, your case manager will be undertaking investigations to understand more about your injury and how it happened. They'll then use this information to make a formal liability decision.
In some cases, if there is no time loss from work, but there is a need for medical treatment, your case manager may accept provisional liability – medical only.
Learn more about provisional liability
Reasonable excuse
A reasonable excuse is a reason for claim service providers to not commence provisional weekly payments. There are seven types of reasonable excuse.
While a reasonable excuse exists, you are 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 your claim.
A reasonable excuse should not be applied for any longer than is necessary.
Learn more about reasonable excuse
Back to top ⇡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 as it has been resolved, your case manager can either provisionally accept your claim or make a formal decision on liability. This formal decision is the gateway to your ongoing access to benefits under the claim.
If your claim is accepted, you are entitled to receive weekly benefits (if your injury results in losing wages), cover for medical expenses, treatment and a range of other supporting benefits enabled under worker compensation legislation.
Learn more about pre-approved treatment
If liability for your claim is declined, you are not entitled to receive any benefits under the claim. Certain notice periods may apply depending on how many weeks you have received weekly payments. If you disagree with a decision to decline liability, you are entitled to have that decision reviewed by someone independent of the initial decision process.
What if I don't agree with the decision?
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 your injury occurred as the aggravation of an underlying condition, you were already experiencing and that aggravation has ceased
- If a new injury is introduced
- If new treatment is requested
- When you lodge a claim for a lump sum if you're assessed to have a permanent impairment
- When you lodge a claim for work injury damages.
Tip: Formal liability decisions are reviewable decisions, meaning you can ask to have them independently reviewed if you disagree with them.
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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 you've submitted a completed claim form with the certificate of capacity from your doctor, your case manager has 21 days to make a formal liability decision. If your 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 your claim.
