What to do if Workers' Compensation Claim rejected in Sth Aust

You lodged a claim for Workers ‘Compensation, and have now received a letter rejecting the claim. What do you do?

The letter of rejection may have come from the Claims Agent, who currently in South Australia, are Gallagher Bassett and Employers Mutual, or it may have come from the employer acting as a self-insurer.

My first recommendation is to get legal advice immediately. In South Australia, a worker has one month, after receiving a decision, to apply to have the decision reviewed. This is by way of Application to South Australian Employment Tribunal. Whilst the Application for Review should be lodged, within one month, don’t be deterred from seeking legal advice or lodging an Application after one month of receiving the decision, as an extension of time can be sought from the Tribunal.

Another important point to consider, is that there can be many and varied grounds for the Claims Agent, or Self Insurer, to have made its decision. These grounds may be based on their interpretation of legislation, medical evidence, or reliance on data programmed into their computer system. It is therefore important not to assume that because a large company made a decision, it must be correct, and therefore it is not worth fighting. In my experience, in a large number of cases, the contrary applies.

A decision could have even been made by administrative error. We had a recent example of this, when our client submitted to the Claims Agent, a couple of medical accounts (totalling less than $200), which were rejected by the Claims Agent, on the grounds that our client’s entitlement to medical expenses, had expired. This was based on the Claims Agent, relying on its computer system, which indicated that as our client had not been in receipt of weekly payments for the previous 12 months, there was no entitlement to claim the accounts.

As soon as our client, send me the letter of decision, I knew it was incorrect. Why? It was because, less than six months ago, I had resolved another WorkCover dispute that the client had with the Claims Agent, relating to a claim for further weekly payments due to an aggravation of the original injury. The effect of resolution, was that the client was entitled to further weekly payments, and therefore at the time the medical accounts were incurred, he had been in receipt of weekly payments within the previous 12-month period.

What transpired, is that, the correct data had not been programmed into the system, and therefore the system generated a non-entitlement flag, when the medical accounts were received. The error was further compounded, after we lodged the Application for Review. Under the legislation, the decision-maker has an obligation to reconsider the decision, prior to the dispute proceeding further at the Tribunal. What alarmed me, was that I had to attend the Tribunal, as the decision-maker had confirmed its decision, after reconsideration. Apparently, when the decision had to be reviewed, during the reconsideration process, the computer system was down, thereby preventing a proper review of the decision. Fortunately, the error in making the decision was accepted at the first Tribunal appearance. The WorkCover scheme, then had to bear the legal costs, which had been incurred.

This example, is one of many examples which illustrate that a worker, on receiving a decision rejecting a claim, or making any adverse decision, SHOULD NOT assume that the decision is correct, or as in the above example, was not worth pursuing. In my view, the scheme should be held accountable.

If you have received a decision in relation to your Workers’ Compensation Claim, that you want advice on, please contact an expert compensation lawyer here at LawCall for a no obligation initial free consultation.