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

Improving dispute resolution

On 4th May 2018 the NSW Government announced plans to reform the dispute resolution process for workers compensation to make it easier to resolve disagreements earlier.

With the launch of the new claims model, icare and EML have taken the lead on this transformation and made changes on how disputes are managed on new claims lodged on or after 1st January 2018.

Under these changes, icare plays a more active role in overseeing and managing disputes in their early stages. The changes are designed to allow faster resolution of disputes and a better experience for both employers and workers.

What is a dispute?

A dispute arises when there is a disagreement with an insurer’s decision on a claim. It is important to note, there is a difference between a complaint and a dispute, and a separate, independent pathway exists for employers and workers to express how they feel about a situation or seek guidance.

Who manages disputes on claims lodged on or after 1st January 2018?

icare has established a new Dispute Resolution team in Workers Insurance to help resolve disagreements about decisions made by EML on claims lodged on or after 1st January 2018..

This team is independent of the original decision and have decision making rights.

They will work closely with employers and workers to resolve disagreements with decisions made by EML affecting an entitlement to benefits (compensation, liability and work capacity disputes).

    When can a disputes application be lodged?

  • Compensation and liability disputes

    Includes weekly benefits, treatment and care, and permanent impairment disputes

    Who can apply

    Employer or their representative worker or their representative

    How to apply

    Complete and lodge a form by email to wiclaimsreviews@icare.nsw.gov.au or phone icare (13 99 22) or EML (13 77 22)

    What the team can do

    Affirm, change or withdraw the decision on review within 14 days of receipt

  • Work capacity disputes

    Includes current work capacity, suitable employment, the amount a worker can earn in suitable employment, the amount of pre-injury average weekly earnings (PIAWE) or current weekly earnings.

    Who can apply

    Worker or their representative

    How to apply

    Complete and lodge a form by email to wiclaimsreviews@icare.nsw.gov.au or phone icare (13 99 22) or EML (13 77 22)

    What the team can do

    Affirm or provide a different decision on review within 30 days of receipt

     

 What will happen when a disputes application is lodged?

A Dispute Resolution specialist will be allocated and all parties to the dispute will be:

  • notified that a Disputes application has been received;
  • provided with a step-by-step guide of the review process - including what they need to, by when and why;
  • given the opportunity to send in any relevant information they would like to be considered: and
  • informed of the review outcome. 

This review mechanism is unique to the new claims model and highlights icare’s commitment to greater transparency and engagement with all NSW workers compensation customers. 

What other support services are available to Employers?

General queries or complaints about a claim being managed by EML should first be raised with EML. If dissatisfied with their response, contact can be made with icare on 13 99 22 or via email to wiclaimsenquiries@icare.nsw.gov.au.  

General enquiries or complaints about regulation of workers compensation in NSW should be directed to the State Insurance Regulatory Authority https://www.sira.nsw.gov.au/contact-us

Workers Compensation Independent Review Office (WIRO) can also be contacted at any time for help. https://wiro.nsw.gov.au/contact-us  

More information

Further information can be found on icare’s website https://www.icare.nsw.gov.au/treatment-and-care/disputes/workers-insurance/what-you-can-dispute/