WorkCover claims: no-fault statutory benefits

When you sustain an injury or an aggravation of an injury at work, the first category of entitlements that are available are known as “no fault” or statutory entitlements. These entitlements are governed by the Workplace Injury Rehabilitation and Compensation Act 2013 and include, amongst other benefits, medical and like expenses, weekly payments and a lump sum benefit if your injury becomes permanent and stable.

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How to lodge a WorkCover claim

To access these no-fault entitlements, you need to lodge a WorkCover claim with your employer. This must be done as soon as possible after sustaining the injury.

The employer then has 10 days to forward the claim to their authorised insurer (or their relevant internal department if they are self-insured) who will make contact with you. The insurer is required to accept or decline your claim within 28 days. If they fail to make a decision within this timeframe, the claim for weekly payments is deemed to have been accepted.  

It is important that you are aware that the insurer may ask you to attend an appointment with a medico-legal doctor to assess your injuries. You are obliged to attend this appointment.

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They may also arrange for a private investigator to take a statement from you. To ensure your rights are protected, it is important to seek legal advice before making a statement.

Medical and like expenses

When you have an accepted WorkCover claim, you are entitled to medical and like expenses.

These generally include:

• doctor’s attendances;
• specialist appointments;
• psychological treatment
• physiotherapy treatment;
• medication; and
• other required medical services to treat your injury.

Depending on the injury, you may also be entitled to home help and gardening services if your injury prevents you from undertaking these tasks.

To ensure that the insurer will fund the services you require, it is important that you ask your treating GP to request the required service from the WorkCover insurer.

It is also important that you claim any out-of-pocket expenses as soon as they are incurred, to ensure that you are reimbursed in a timely manner.

If the insurer rejects a request for reasonable medical and like services, this decision can be disputed by lodging a request for conciliation with the Accident Compensation Conciliation Service (ACCS). Guardian Injury Law can provide you with advice about this process and any offers made by the insurer.

Weekly payments and return to work

To receive weekly payments for loss of income once you have an accepted WorkCover claim, you need to submit valid certificates of capacity to your employer. These are not standard “sick certificates”; they are specific WorkCover certificates.

Your GP will be able to issue you with these certificates. It is important that the first certificate covers a 14-day period, and every certificate thereafter covers a 28-day period. Your certificates of capacity should not miss any days to ensure that you receive the correct entitlements.

The Workplace Injury Rehabilitation and Compensation Act 2013 provides for the following weekly payments:

• In your first 13 weeks of incapacity, you are entitled to 95% of your pre-injury average weekly earnings (PIAWE).
• From 14 weeks to 130 weeks, you are entitled to 80% of your PIAWE.
• At 130 weeks, your weekly payments will stop, unless you can display that you have no current work capacity, not only for your pre-injury job but for any job in the labour market.

It is important that you are aware that after 52 weeks of entitlements, the insurer no longer takes into account any shift allowances, bonuses or overtime when calculating your PIAWE.

Your certificates of capacity will also stipulate whether you have a work capacity. If your doctor certifies that you have some capacity for employment you will need to engage with your employer and an occupational rehabilitation provider to ensure that you return to work in a safe and appropriate manner.

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At Guardian Injury Law, we often see clients who have had their weekly payments terminated because the insurer has formed the view that a worker has a work capacity, or their injury is no longer related to employment.

If your weekly payments are terminated, make sure you seek advice from Guardian Injury Law to determine if the insurer’s decision should be disputed.

Impairment benefit claim – lump sum payment

If your injury is permanent and has stabilised, you may have an entitlement to an impairment benefit (a lump sum compensation payment) in accordance with the Workplace Injury Rehabilitation and Compensation Act 2013.

Impairment benefit claims can generally be lodged 18 months after the injury has occurred as long as the injury is stable. The injury does not need to have been caused by the negligence of your employer or any other party. The term “stable” means unlikely to markedly improve or decline. Your treating doctors will be asked to provide their opinion regarding this.  

To receive lump sum compensation under an impairment benefit claim, your injury needs to meet a threshold in accordance with the 4^th edition of the American Medical Association Guides (AMA Guides).

• For spinal injuries, you need to have a greater than 5% whole person impairment (WPI);
• For all other physical injuries, you need to have a greater than 10% WPI; and
• For psychological injuries, you need to have a greater than 30% whole person impairment.

How will Guardian Injury Law help you?

At Guardian Injury Law, we carefully assess all injuries to determine if they will meet the required thresholds under the AMA Guides. We also ensure that all injuries are included in the claim to ensure that your entitlements are maximised.  

We are skilled at obtaining the relevant evidence to support claims to ensure the best outcome possible.

Once an impairment benefit claim has been lodged, the insurer has 120 days to have you assessed by a suitably qualified medico-legal specialist to assess your injuries and then provide a determination. Guardian Injury Law is able to assess the insurer’s determination and provide advice as to whether it should be accepted or alternatively appealed (including claims that are outright declined), to obtain the compensation you are entitled to.