When deciding a physical claim, an insurer will apply criteria from the Workers' Compensation and Rehabilitation Act 2003 (the Act). Criteria can include considering whether:
- the claim was made within the time limits
- the person was employed at the time of the injury by the employer
- the person is considered to be a worker
- the injury was caused by a work-related event, and
- the person was injured out of, or in the course of, employment, if the employment is a significant contributing factor to the injury.
Depending on the type of injury or how the injury happened, an insurer may require further information and apply slightly different criteria. These types of claims include:
- psychological and psychiatric injuries
- industrial deafness
- injuries sustained travelling to or from work or on breaks such as morning and afternoon tea and lunch
- aggravated injuries or ongoing symptoms
- work-related respiratory diseases or diseases contracted in the course of employment, for example Q-fever
- fatalities caused by a work-related event or by latent onset injuries such as mesothelioma or malignant skin cancer.
How a WorkCover claim is processed
Once a claim has been made, it is allocated to a WorkCover Queensland claims representative to be determined.
WorkCover determines claims as quickly as possible and will generally contact both the worker and employer within three business days of the claim being made.
Workers have the opportunity to give details of the injury and event before we make our decision. We'll also speak to their employer to get further information (such as confirmation of employment and wage details) and to notify them that a new claim has been lodged on their policy.
How long does it take to decide a claim?
When workers and employers provide true and accurate information about the claim, WorkCover is able to make a decision very quickly.
A decision on a claim can take up to 20 business days, especially if we have difficulty getting the information we need such as information from the employer, the work capacity certificate or information from doctors.
If we can't determine the claim within this timeframe, we will contact the worker verbally and in writing to let them know why a decision hasn't been made.
The worker can request to have the insurer’s failure to decide the claim within 20 business days reviewed by the Workers' Compensation Regulator if unhappy with the reasons provided.
Information needed to decide a claim
WorkCover gathers information from the worker, employer, doctors and other people, such as witnesses to the event or independent medical examiners, to help us make our decision.
Once we've gathered enough information to decide the claim, both the worker and the employer will be informed of the decision.
What happens if the claim is accepted?
If a claim is accepted and a worker receives weekly compensation, their employer will be required to pay the first payment of weekly compensation (this is the employer’s excess).
WorkCover will confirm the worker’s bank details and manage all further weekly compensation payments. If a claim requires ongoing management or assistance with return to work, it will be case managed by one of our customer advisors.
Find out more about the types of payments and support available.
What happens if the claim is not accepted?
If an application is not accepted, our claims representative will speak to the worker and explain the decision that has been made. A letter will be sent explaining the information considered and the reason why the application was not accepted. Find out more about what happens if a claim is not accepted.
Common law only claims
There may be times when an injured worker may elect not to claim for statutory benefits and proceed directly to common law. It's important to note however these applications are subject to the same injury investigation and review processes as statutory claim applications.
As with all claims, WorkCover's focus is first and foremost on rehabilitation and return to work and hence this type of application will be reviewed for possible opportunities for this type of intervention.
How a self-insurer processes a claim
While both WorkCover and self-insured employers must comply with the same legislative requirements for determining claims, self-insured employers may have different processes or procedures they follow when determining claims. Therefore it is best to speak to the claims officer regarding any specific queries.
I’m confused about a claim. Who can I talk to?
- Call WorkCover Queensland on 1300 362 128
- If your employer self-insures, you can contact the relevant claims department
- Employers can contact CCIQ’s Workers’ Compensation Helpline
- Workers can contact the Queensland Council of Unions’ Workers’ Compensation Advisory Service
- Last updated
- 10 January 2019
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