The Decision Process of the Insurer
The one question the insurer needs to answer prior to accepting liability for a claim is “Is the injury work related?”
During this process you will need to provide proof of the injury and your employment most importantly but you may also be interviewed, investigated You will be asked to give permission to the insurer to gather certain documents and information.
No fault legislation
NSW Work cover is a no-fault scheme. No one has to demonstrate that you or your employer have done anything wrong (are "at fault") to be receive for compensation.
Insurers need to follow the principles of natural justice in making a decision, this means giving everyone who might be directly affected by a claim a chance to be heard. Specifically you and your employer.
In deciding liability an insurer will need to answer two questions.
1. Is it a injury covered by the act? and
2. Is the injury work related?
Proof that an injury is work related
Despite it being "no fault" there is a need for the insurer to be satisfied that the injury is work related, their work in satisfying will feel like they are blaming you.
Proving you were employed.
The insurer need to will obtain information about your employment through documents such as:
- A current pay slip
- Payroll number
- Bank statement that includes regular employer payment entries
- The contract of employment.
People who aren't in a traditional employment contract may be "deemed employees" by the Act and are therefore covered. please see your union or contact the regulator or the IWSN to check.
Proving a medical relationship
Your doctor provides the insurer with the first medical proof through the Work Capacity Certificate but further proof may be required in most circumstances. This information may come from:
- The treating doctor and/or hospital (after you give permission for them to contact these)
- An external medical assessment by an insurers medico-legal examiner (called an Independent Medical Examiner).
- A review of your medical history.
Your Medical Records.
The insurer will ask for access to your medical records during the assessment. This is only for relevant records (i.e history for the area of the injury or prior injuries that may impact that area - not your whole file).
There are several exclusions from claiming workers compensation.
- Heart attacks and strokes are excluded (unless significant proof that they are work related is present).
- Reasonable administrative management action (done in a reasonable manner).
- The injury was the result of serious and wilful misconduct by you.
- Your injury was intentionally self-inflicted.
- A pre-existing injury. (a claim for an exasperation or reoccurrence due to work can still be made though).