What if my WorkCover Claim is Rejected?

Receiving a decision rejecting your WorkCover claim can be frustrating and concerning. Many workers assume that a rejection means there are no further options available. However, that is not necessarily the case.

Queensland law provides a review and appeal process that allows workers to challenge decisions they believe are incorrect. This guide explains what a rejection means, the options that may be available, and the steps you should consider taking next.

Why Claims are Rejected

A claim can be rejected for many reasons. Common examples include insufficient medical evidence, disputes regarding whether employment contributed to the injury, delayed reporting of the injury, concerns about causation, or allegations that the condition is unrelated to work.

 Understanding the reason given by the insurer is important because it will often determine what further evidence is required and whether a review is likely to succeed.

Step 1: Review the Decision

The decision letter issued by WorkCover is one of the most important documents in the review process. It should explain why the claim was rejected and identify the evidence relied upon by the insurer.

Understanding those reasons is critical. A successful review application will usually need to address the concerns identified in the decision rather than simply restating the information already provided.

Step 2: Seek Reconsideration or Further Evidence

Before commencing a review, it is often worth considering whether additional evidence can be obtained. Depending on the circumstances, this may include updated reports from treating practitioners, specialist opinions, workplace records, witness statements or other documentation relevant to how the injury occurred.

Additional evidence is often the difference between an unsuccessful claim and a successful review.

Step 3: Apply for an Independent Review

If you believe the decision is incorrect, you may apply to the Workers' Compensation Regulator for an independent review. The Regulator will reconsider the decision and assess the evidence available to determine whether the rejection should be confirmed, varied or set aside.

Applications generally must be lodged within three months of the decision.

Is It Worth Challenging a Rejection?

A rejection does not necessarily mean your claim lacks merit. Many successful review applications involve additional evidence that was not before the insurer when the original decision was made. Whether a challenge is worthwhile will depend on the reasons for rejection, the evidence available and whether further information can be obtained to address the issues identified by WorkCover.

Key Time Limits

• 6 months from the date of injury (or symptom onset) to lodge the original claim;

• 3 months from the rejection decision to apply for review by the Regulator, and;

• 20 business days from the review decision to appeal to the QIRC.

Note: some decisions — such as refusal to approve specific medical treatment — cannot go through the Regulator review step and must be appealed directly to the QIRC. We can confirm which pathway applies to your decision.

When Should You Seek Legal Advice?

Although some workers choose to manage the review process themselves, legal advice can be particularly helpful where the reasons for rejection are unclear, additional medical evidence may be required, or important time limits are approaching.

Advice is also often beneficial in claims involving psychological injuries, complex medical issues or disputes about causation.