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One of the most common reasons clients come to us is because they’ve had workers compensation payments or medical treatment denied. We have a very high success rate in getting these denials overturned, and we can generally get funding to cover our fees so there’s nothing for our clients to pay.
In this article, we share advice and expert tips from our workers compensation lawyers based on thousands of successful cases. We explain in simple terms what to do if you receive a section 78 notice (a letter) telling you your workers compensation claim is denied.
An insurer doesn’t have to accept and pay your workers compensation claim without questioning it. But if it denies your claim, the insurer must issue you with a Section 78 notice, or decision notice. This is a letter outlining the reasons why your claim has been denied. Your letter may or may not state that it’s a section 78 notice.
The letter must include:
In our experience, here are the main reasons workers compensation is denied.
This happens when the insurer disputes your capacity to work. They’re generally not saying your injury didn’t happen, just that they think you can work more than you have been. This is a very common reason for denied claims.
If expensive surgery is approved, like a knee replacement or fusion surgery, it often increases your WPI (whole person impairment) rating, which the insurer generally wants to limit. Our lawyers can help you with doctor referrals and build the evidence to prove your surgery is reasonably necessary.
These claims are often denied by insurers, and it can come down to one word against another. However, our lawyers are experienced at finding holes in insurers’ denials and presenting factual cases to support psychological claims.
Many of our clients come to us for help when their doctor has recommended treatment, but the insurer has declined to cover it. However, the insurer is often denying the treatment ‘pending further information’, so their decision is quite easily overturned once we provide the required information. We often see treatments like cannabis being denied by insurers, but with the right evidence, we can often get these treatments approved.
The insurer may dispute your weekly payment amounts or reject benefits like vocational assistance or cleaning services. Getting these payments approved for you is generally a case of addressing the insurer’s reasons for denial and providing the evidence needed to get them approved.
Expert tip: Sometimes it comes down to using the right doctor who understands the workers compensation scheme and the correct way to assess your injuries. We have a network of doctors we refer our clients to, to make sure their medical assessments are done correctly to support their workers compensation claims.
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Get startedIf your medical treatment or surgery has been denied by the insurer, then you’ll be liable for pay the medical bills yourself. But that’s not the end of the road – as long as we can show your treatment is ‘reasonably necessary’, it’s very likely we can get the decision overturned so that the insurer will pay your medical bills.
Yes you can – you don’t need to accept the insurer’s decision if it’s unfair to you. We mentioned earlier that the insurer must provide you with details of why it’s denying your claim. This is the starting point for appealing – you need to address the reasons the insurer has raised and provide additional information to show why your claim should be approved.
Expert tip: Once we’ve made sure all your other entitlements are approved, we often discover that our clients are entitled to an additional lump sum if their injury was caused by negligence. This is called a Work Injury Damages claim, and these lump sums can be substantial.
There’s no time limit to appeal a section 78 notice. A lot of people call us thinking they only had two weeks and that they’ve missed out, but that’s not right. Once you submit the appeal the insurer has 2 weeks to respond, but there’s no time limit for you as the injured worker.
There are three appeal processes available to you:
This is where you provide additional information you think is relevant to help the insurer review its decision.
This is an independent statutory office that can help find solutions to disputes by contacting the insurer on your behalf.
The PIC is an independent tribunal that helps resolve workers compensation disputes between injured workers and employers/insurers.
Don’t worry if that all sounds a bit daunting. Our lawyers can handle the whole process for you, and we’ll apply to the IRO for funding so that there’s no cost to you.
Remember, to be successful in overturning the insurer’s decision on liability, you need to make sure you thoroughly review all the evidence gathered by the insurer that led to its decision and present a strong case for why you believe they’re liable. Our lawyers will take care of everything, and we have a strong track record of success with getting these decisions overturned. You can call 13 15 15 for free advice from one of our specialist workers compensation lawyers.
Our senior lawyers will assess your case for free.
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