If this happens, you may feel like you’ve hit a dead end, but it’s important to remember that a rejected compensation claim is not necessarily the final word. In South Australia, there are steps you can take to challenge the decision.
This article sets out the action you can take if your claim has been rejected. The information is general only, and we recommend consulting with us, as experienced personal injury and workers’ compensation lawyers, to help you navigate the claims process.
Determine Why Your Workers Compensation was Rejected
When a workers compensation claim is rejected, the ReturnToWorkSA (RTWSA) claims agent or a self-insured employer must send you a letter, which is referred to as a ‘letter of determination’ and which outlines the specific reasons why your claim was rejected.
Common reasons why workers’ compensation claims are sometimes rejected include:
- Dispute over the cause of the injury: The insurer may argue that your injury was not caused by your work or did not happen in the course of your employment. There are also varying levels of significance in terms of the cause of the injury, and to add to the complexity, this also varies between physical injuries and those related to mental harm.
- Pre-existing condition: The claims agent may determine that your injury is a result of a pre-existing medical condition, rather than a new work-related injury.
- Insufficient evidence: The claim may have been rejected due to a lack of medical evidence (i.e., doctors’ reports), witness statements, or other documents to support your case.
- Late claim submission: There are time limits for lodging a workers compensation claim and missing these could cause your claim to be rejected.
- Disagreement on your capacity to work: The claims agent might agree that you have an injury but disagree with your doctor’s assessment of your capacity to work.
Understanding the reasoning in these decisions is the first step in building your case so the decision can be reconsidered or reviewed.
Workers Compensation is a complex area of law because the legislation that underpins the workers compensation scheme; the Return to Work Act 2014 (SA), continues to evolve and develop by the judgments made by the South Australian Employment Tribunal (SAET).
For this reason, it is imperative that you move quickly and seek our advice to assist in presenting the best case possible.
Lodging An Appeal with the South Australian Employment Tribunal
The SAET has the power to review rejected workers’ compensation claims and other applications related to your medical treatment or return to work plan.
A breakdown of the typical process is:
- Lodge an A02 – Application for Review (Return to Work): This is the formal step to review a decision or determination and this must be done within one month of receiving the letter of determination. While in some cases it may be possible to apply for an extension, it is always best to act quickly to avoid potential issues. The application form can be found on the SAET’s website.
We recommend that you seek our advice when applying for a review. There are several grounds for rejecting a claim, and just because an unfavourable decision has been made, does not mean the decision is incorrect. As experienced personal injury and workers’ compensation lawyers, we can examine the legal issues such as misinterpretation of the legislation, the medical evidence or reliance on incorrect data.
- Reconsideration of decision: After your application is lodged, your case will be allocated to an SAET Commissioner and a copy of the application sent to the RTWSA claims agent and other relevant parties (including your employer). RTSWA has 10 business days to reconsider its original decision. It will notify you and SAET whether the decision to reject your compensation claim is confirmed or varied.
SAET’s Dispute Resolution Process
If your claim is still denied, you will need to consider whether to accept the decision or proceed through SAET’s dispute resolution process. The SAET’s main goal is to resolve disputes fairly and efficiently. The SAET uses methods like compulsory conciliation conferences to help parties resolve their issues and come to an agreement. In some instances, a matter may be referred to an Independent Medical Adviser.
The SAET’s dispute resolution process usually begins with the pre-conciliation phase, where a member of the SAET reviews the case to confirm the correct information is put before the SAET member.
This is followed by an initial directions hearing (in person or by telephone) to prepare for a compulsory conciliation conference. This is a preliminary meeting to consider the grounds for review, clarify the issues in dispute, and set out what evidence is needed.
The compulsory conciliation conference is the primary method for resolving a dispute at the conciliation phase. It is an alternative to a formal court hearing, where parties try to reach an agreement with the help of an SAET member. The SAET member will act as a mediator to help the parties reach an agreement. The goal is to resolve the matter without the need for more formal hearings. Many claims are resolved at this stage.
If a settlement is reached, it is formally documented.
If the conciliation conference is unsuccessful, the matter may proceed with a more formal process before a Presidential member of the SAET. At this level, the process is more formal and all parties will need to begin to finalise and present their evidence in order to prepare for a trial, where a presiding member will adjudicate and reach a determination.
Conclusion
Unfortunately, a person’s claim for workers’ compensation sometimes gets rejected.
If you find yourself in this situation, it is important to understand why your claim was rejected so you present a strong case to have that decision reviewed.
Your application to review a decision must contain all the necessary information required for the best chance of success. While it is possible to navigate the review process on your own, it is extremely complex and intimidating.
As experienced workers’ compensation lawyers, we can:
- Review the decision and help you understand the specific legal and medical issues in your case.
- Advise you about gathering the right evidence to build a strong case.
- Manage the paperwork and formal process of lodging an application with the SAET.
- Promote your interests in all stages of the dispute.
- Maximise your entitlement and the potential of your claim.
If you or someone you know wants more information or needs help or advice, please call 08 8443 4888 or email [email protected].