My Comcare work injury claim has been rejected – where to from here?

Making a Comcare claim for a work injury can be a daunting process – but if the claim is rejected, it can be even more overwhelming and stressful.

It is critical to know that if your claim is rejected there are steps that can be taken to challenge this. Legal assistance is crucial to ensure the best outcome possible.

The rejection of a Comcare claim comes with a two-step process of review. Read on, as it is vital that you understand all your rights.

Step 1 – Reconsideration Request

The first step is referred to as the ‘reconsideration’ process and involves writing to the insurer and asking them to ‘reconsider’ the decision to deny the claim. There are time limits which apply – a reconsideration request must be submitted within 30 days of the rejected claim. It is useful to set out why you believe the insurer has ‘got it wrong’ and provide any further supportive medical evidence (such as a medical certificate and/or a letter of support from your doctor). It is useful to seek legal advice at this point and have assistance with requesting a reconsideration.

The insurer is then obligated to ‘reconsider’ the rejected claim, and after that process is finalised it will provide a Reviewable Decision either overturning its initial decision (to accept the claim), or confirm its initial rejection of the claim.

This second determination letter is referred to as a Reviewable Decision.

Step 2 – Application for Review at the Administrative Appeals Tribunal (AAT)

If your claim is confirmed as rejected you have review rights to challenge this at the Administrative Appeals Tribunal. Again, there is a time limit which applies which is 60 days from when the Reviewable Decision is made. The AAT is an entirely independent tribunal. Again, it is important to consider seeking legal advice to assist with this process as it is not straight forward.

We frequently file appeals to the AAT for Commonwealth employees who have disputes in relation to their work injury claim.

The AAT process can take several months, at least, to resolve your dispute.  Thankfully the focus of the AAT is a conciliatory one. That is, rather than proceeding to a trial, the focus of the initial discussions is to try and reach a settlement.

Usually the AAT process will take approximately four-to-six months. Of course, each case depends on what is involved, but this is a rough estimate.

Information gathering

Within that timeframe a lot of relevant medical information and other documentation must be obtained and considered. Medical notes may be summonsed and doctors may be asked to provide reports.

Of course, we will keep you updated in relation to the progress of your dispute through the AAT.  We will also keep you informed when any relevant medical evidence is obtained.

Settlement conference

It is likely your matter will then be listed for a settlement conference at the AAT.  You will need to attend that conference and in light of current COVID-19 restrictions it is typical for that to take place via phone or video conferencing software.

It is only if the negotiations at the AAT fail to achieve a result that your matter might be listed for a Trial.  This is typically at least six months or more away from when an appeal at the AAT is filed.  A trial is a last resort, and it rarely occurs.  Whether or not a trial is necessary depends a lot on the attitude and the position that your employer or insurer takes in relation to your work rejected injury claim, and of course your own instructions.

If your claim is successful at the AAT we can recover a significant proportion of your legal costs and disbursements from your employer or the insurer, on your behalf.

Summary:

If you have received a decision by your employer or insurer rejecting your work injury claim in either a state-based scheme or the Commonwealth scheme (i.e., under the SA Return to Work Act or the Commonwealth Safety Rehabilitation and Compensation Act) you should seek legal advice about challenging that decision.

Your individual circumstances are paramount to determining the likelihood of being able to challenge any rejected claim so you should seek advice in regards to your specific circumstances as soon as the claim is rejected.