Workcover Claims What You Need to Know!

Workcover Queensland is a Queensland government owned statutory body. With the exception of self-insurers, it is the exclusive provider to Queensland employers of accident insurance for workers who have suffered work-related injuries. The Workers’ Compensation and Rehabilitation Act 2003 (Qld) (‘WC Act’) provides the framework for managing workers’ compensation and rehabilitation in Queensland.

In this article we will examine what constitutes an injury and the Workcover claim process.

The WC Act defines an ‘injury’ as a “personal injury arising out of, or in the course of, employment if the employment is a significant contributing factor to the injury.”

The types of injuries can be summarised as follows:

While the employment needs to be a significant contributing factor, there are exceptions in the case of a worker’s ordinary recess period (eg. normal lunch break) or for journey claims (eg. travelling to and from work).

The definition of injury under the WC Act has an exception for psychological and psychiatric disorders arising out of, or in the course of, any of the following:

A worker who has suffered an injury must complete a Claim Form and obtain a Work Capacity Certificate (‘WC Certificate’) from their treating doctor and then provide these to Workcover Queensland (or self-insurer). A WC Certificate can also be completed by a nurse practitioner for a minor injury or a dentist for an oral/dental injury.

The worker should also notify their employer of the claim, preferably by providing a copy of the Claim Form, and a copy of the WC Certificate. The Claim Form has a section for both the worker and the employer to complete so the form can be submitted to Workcover Queensland either jointly or separately.

An employer has an obligation to report an injury immediately or within eight business days of becoming aware of the injury unless there is a reasonable excuse. Examples of a reasonable excuse include that the employer has not been reliably informed about the injury, there is evidence that the injury was not sustained in the course of the employment, or there is a technical or other issue that led to a short delay to report within the time frame.

In practice, the requirement to report tends to be applied when an employer knows a worker has sustained an injury for which workers’ compensation may be payable under the WC Act but the worker does not notify Workcover Queensland (or self-insurer).

Unless the worker and the employer have already jointly submitted the Claim Form to Workcover Queensland, then Workcover Queensland will contact the employer to obtain a response. This can be done by completing the employer section of the Claim Form or via Workcover Queensland’s on-line services.

Workcover Queensland is required to make a decision within 20 business days after the application has been made. However, in practice a decision may not be made within this time frame due to an inability to obtain information.

Workcover Queensland (or self-insurer) will then either accept or reject the claim. A dissatisfied party may ask for a reasons for decision within 20 business days of being advised of the decision.

An employer (or worker) may lodge an application for review with the Office of Industrial Relations (‘OIR’) within 3 months of receiving the decision of Workcover Queensland (or insurer). A party lodging a review is known as the applicant.

The OIR Review is an impartial administrative review conducted by a Review Officer of the OIR. It is not a court process. An applicant may elect to have a right of appearance before the Review Officer.

The Review Officer will endeavour to make a decision within 25 business days of the review application being lodged unless an extension has been granted or to comply with the requirements of procedural fairness.

The potential decision outcomes of a review will be to confirm, vary, set aside and substitute another decision or set aside the decision and return the matter to the Workcover Queensland with directions considered appropriate.

A party who is dissatisfied with the review decision can lodge an appeal with the Queensland Industrial Relations Commission (‘QIRC’) within 20 business days of receiving the decision.

Where an employer lodges an appeal, the OIR will defend the review decision on behalf of the Workers’ Compensation Regulator (being the respondent). Where a worker lodges an appeal, the OIR will manage the defence of the review decision on behalf of the Workers’ Compensation Regulator (being the respondent) in the QIRC.

The appeals process involves a de novo hearing whereby a completely new trial or review is undertaken. The QIRC will have an initial conference and if still unresolved then proceed to a hearing.

The potential decision outcomes of an appeal will be to confirm, vary, set aside and substitute another decision or set aside the decision and return the matter to the respondent with directions considered appropriate.

Employers need to be mindful of what constitutes an ‘injury’ under the WC Act so they are in an informed position when required to respond to a claim. While physical injuries are easier to verify, it can be quite difficult with respect to psychological and psychiatric claims.

If Workcover Queensland decides to accept a worker’s application, then it is important to obtain a copy of the decision and determine whether there are good prospects for a review application with the OIR. There is a final review process by way of an appeal to the QIRC which will involve a conference and final hearing of the matter.