Types of workers insurance disputes

If you think your insurer has got something wrong, you can ask for a review of the decision.

When you’ve been injured at work, there are many decisions that need to be made by both your employer and the insurer when you make a claim.

If you don’t agree with a decision at any point along the journey, you can raise it directly with them.

For a fast and cost-effective resolution, we encourage you to try and resolve disagreements with your employer or insurer directly.

But if you can’t resolve the issue, there are a range of ways you can lodge a dispute. You can lodge a dispute about:

  • Liability
  • Permanent impairment
  • Injury management
  • Medical, hospital and rehabilitation

Work capacity decisions

If you disagree with a decision that has been made about your work capacity, you may request an internal administrative review from the insurer. If you need assistance or information, you can seek help from the insurer, the State Insurance Regulatory Authority’s (SIRA) Customer Service Centre on 13 10 50, the Worker Compensation Independent Review Officer (WIRO) on 13 94 76 or your trade union.

 

Liability disputes

If the insurer disputes the liability of your claim, there are ways to dispute that decision.

Liability under workers insurance means deciding whether you meet the legal requirements for workers compensation for your injury.

If an insurer finds that the legal requirements for workers compensation are not met, they will be unable to pay compensation for your injury.

Examples of when these disputes can happen include:

  • the insurer does not consider you to be a ‘worker’ under the legislation
  • the insurer determines your employment was not a substantial contributing factor to the injury
  • the claimed medical expenses are not reasonably necessary because of the injury

If you disagree with a decision regarding the liability of your claim, you can challenge it.

You can also find more information on Liability disputes on the workers insurance regulator’s website.

How to lodge a dispute

Permanent impairment disputes

Sometimes, you and the insurer may disagree on the level of permanent impairment.

This is usually when both you and the insurer have sought permanent impairment assessments but the results do not align.

If you disagree with the level of permanent impairment provided by the insurer, there are ways you can resolve it.

You can also find more information on Permanent impairment disputes on the workers insurance regulator’s website. 

How to lodge a dispute

Injury management disputes

There are a range of options to help resolve disputes about injury management. Types of injury management disputes include:

  • where there is no injury management plan or it has not been followed
  • there is no return to work plan or it has not been followed
  • where no suitable work has been provided for you
  • your capacity to perform duties is disputed
“Employers are required to provide suitable employment when you are unable to return to your normal duties after an injury.”

 Suitable employment (sometimes also referred to as suitable duties, suitable work, pre injury duties, modified duties, or light duties) can include:

  • changing hours of work (eg working part time)
  • modifying duties (eg no longer doing any heavy lifting)
  • a different job (eg office work rather than manual work)
  • providing training opportunities (eg to do another job in the company)
  • trying a different workplace

If you disagree with how your injury is being managed or your suitable employment in the workplace, please see How to lodge a dispute for more information.

You can also find more information on Injury management disputes on the workers insurance regulator’s website.

Work capacity reviews

Work capacity is defined as your ability to work in any type of suitable employment, not just the type of employment you were in prior to an injury.

It is determined by a number of factors including functional, vocational and medical status, and helps to inform decisions about your ability to return to work (either in the pre-injury job, or another suitable job with the pre-injury employer, or at another place of employment).

Disagreements can happen when you and the insurer don’t agree on:

  • what constitutes suitable employment
  • how much you can earn in suitable employment
  • whether you have current work capacity

If you disagree with a work capacity decision, you can have it reviewed.

You can also find more information on Work capacity disputes on the workers insurance regulator’s website.

How to lodge a dispute

Medical, hospital and rehabilitation disputes

Sometimes you and your insurer won’t agree about medical, hospital and rehabilitation treatment.

Medical, hospital and rehabilitation treatment can include:

  • a review by your Nominated Treating Doctor
  • physiotherapy treatment
  • surgery
  • ambulance services
  • diagnostic investigations

Examples of where disagreements can happen, include:

  • the insurer does not consider that the treatment is reasonably necessary
  • the treatment or service is not considered to be payable under the workers compensation legislation

You can also find more information on Medical, hospital and rehabilitation disputes on the workers insurance regulator’s website.

In the workers care program, if you disagree with a decision icare has made about your medical, hospital and rehabilitation treatment, talk to your coordinator in the first instance. They might contact other people involved with you, such as your service provider who requested the treatment. Your coordinator may suggest arranging a meeting to discuss the issues with your service provider to agree on solutions.

For more information about disputes within the workers care program, download our information sheet.

If you’re not happy with a decision made by the insurer about your liability, permanent impairment or work capacity, you will need to use the insurer’s dispute process.

How to lodge a dispute