WorkCover Claim Denied — What to Do Next

Why Claims Are Denied

Common reasons for claim denial include the insurer determining the injury is not work-related, insufficient medical evidence, pre-existing conditions being identified as the primary cause, the claim being lodged outside the limitation period, and section 11A defences (for psychological injuries where the employer's action was reasonable).

Provisional Liability

Under section 267 of the Workplace Injury Management Act 1998, insurers must commence provisional weekly payments within 7 days of receiving a claim, even while the claim is still being determined. This provisional liability period lasts 12 weeks. During this time, you receive weekly payments and can access treatment while the insurer investigates the claim.

Internal Review

If your claim is denied, you can request an internal review by the insurer. The review is conducted by a different person within the insurer's organisation. You should provide any additional medical evidence that supports your claim. This is where strong, thorough documentation from Claims Doctor can make a significant difference.

Personal Injury Commission

If the internal review upholds the denial, you can apply to the Personal Injury Commission (PIC) for an independent determination. The PIC is an independent tribunal that resolves workers compensation disputes in NSW. You can represent yourself or engage a lawyer. Medical evidence is central to PIC proceedings.

Legal Representation

A workers compensation lawyer can advise you on the strength of your case, represent you at the PIC, and negotiate with the insurer. Many workers compensation lawyers offer free initial consultations and work on a no-win-no-fee basis.

Strengthening Your Medical Evidence

The single most important thing you can do when a claim is denied is to ensure your medical documentation is thorough, accurate, and clearly demonstrates the link between your work and your injury. Claims Doctor can provide an independent clinical assessment →