Workers’ Compensation – The Claim Decision

January 28, 2020 FAQs Know Your Rights News Our Resources

Each year, the union office receives thousands of questions from concerned members in regard to Workers’ compensation. Below are a series of questions and answers concerning the Claim Decision.

Q. Once I have submitted a claim, how long will it take to get a decision?

  • The Insurer has 20 business days after you submit your claim to make a decision. They can either accept or reject your claim.
  • We recommend that you ring the Insurer after you have submitted your claim form and associated paperwork at your store to confirm that your workplace has sent it to the Insurer.
  • Find out who your Claims Manager is while you are on the phone and introduce yourself to him or her.

Q. What if the decision on my claim is not made within the time limit?

  • Unless your Claims Manager can assure you that the decision on your claim will be made within the next two days after the time limit has expired, you are entitled to ask him or her to provide you with a letter explaining why the decision was not made within the legislated time limit. The Insurer must provide you with their reasons in writing. When you receive this letter detailing their reasons, please phone the union office.

Q. What may be expected of me while the Insurer is considering their decision on my claim?

  • In order to make their decision, the Insurer may wish to take a more detailed statement from you on how your injury occurred. They may also direct you to go to see a Doctor or Specialist of their choice for an examination and report. (This is standard procedure).
  • It is important to remember that any Doctor that the Insurer sends you to see is for examination and report purposes only. Such Doctors are not your treating Doctor and cannot treat you themselves or refer you elsewhere for treatment.

What if my first Medical Certificate lapses while I am still waiting for a decision on my claim?

  • Never let your Workers’ Compensation Medical Certificate expire. Any gap between the finish date on one Certificate and the start date on the next Certificate will cause you problems and payment delays with the Insurer. The best way to avoid this is to always ensure that you visit your treating Doctor and obtain your next Certificate before your current Certificate expires.

What can I do if the decision on my claim is rejected?

  • The Insurer is required by law to advise you in writing of the decision they make on your claim. If their decision is to reject your claim, they must provide you with a detailed statement of reasons for their decision in writing.
  • If the Insurer rejects your claim, you have the right to have their decision independently reviewed. If successfully reviewed, the Insurer can be directed by the Regulator to accept and pay the claim.
  • Contact the union if this happens to you.
  • There are time limits involved in lodging a review so please contact the union office ASAP.

If my claim is accepted, how long will it take to start before I receive compensation benefits?

  • You should start to receive weekly compensation benefits to replace lost wages within 10 business days.
  • Your first benefit payment should include backpay to cover lost wages to the first date that you were medically certified as being totally incapacitated for work.
  • Check the weekly rate of compensation benefits when you receive your first benefit payment. In most cases, you should be receiving the same amount that you would have received in wages normally had you been working.

For further information, please contact the SDA 07 3833 9500.