If you are a worker in Queensland and the insurer has made a decision on your claim and you disagree with that decision you may be able to lodge an Application for Review with the Workers' Compensation Regulator.
Not all decisions made by an insurer on a claim can be reviewed, however those insurer’s decisions which can be reviewed include:
- Rejection or acceptance of a claim;
- Termination, suspension, increase or decrease of a weekly benefit;
- Refusal of an entitlement to certain expenses; and
- Refusal to waive the time-frames involved in lodging a claim.
The Workers' Compensation Regulator have the power to either :
- confirm the original decision;
- vary the original decision;
- set aside the original decision and substitute another decision; or
- set aside the original decision and return it to the insurer with directions.
The Workers' Compensation Regulator does not reinvestigate a claim. A decision on a review is made based on information on the existing claim file and any additional relevant information provided by you in your review and your employer.
LODGING AN APPLICATION FOR REVIEW
An Application for Review of an insurer’s decision must be lodged within three months of receiving the decision.
You must identify on your review application the decision you want reviewed.
It is important for you to also explain in your review application why you believe the insurer’s decision is not correct and provide where possible additional relevant information and documents to demonstrate your points.
It is not sufficient for you to simply state you disagree with the insurer's decision.
When you are notified by WorkCover or the self-insurer of their decision on your claim you should request the insurer provide you with their written reasons of the decision.
The written reasons will assist your understanding of how the insurer reached their decision, the points you will need to address in your review and if you need to provide further documents and information in support of your review.
For example; if a claim was ceased based on an independent medical examination report that stated the injured worker is no longer incapacitated by the work-related injury.
For their review, the injured worker should seek written medical opinion from their treating specialist or doctor which clearly states that the injury is still causing the worker some incapacity to work and the injury requires further treatment to improve. The worker should provide this written medical opinion to the Regulator in support of their review application.
An Application for Review must be completed on the approved form available from the Workers' Compensation Regulator or downloaded from their website athttp://www.qcomp.qld.gov.au/__data/assets/pdf_file/0013/3109/Form-542-3-Application-for-a-claim-review---fillable-form.pdf
You should attach to your review application a document setting out your reasons why you disagree with the insurer’s decision. If you have documents such as diary notes, medical reports, witness statements etc which are relevant to your argument that the insurer’s decision is not correct you can attach these to your review document.
An Application for Review must be completed and lodged with the Regulator's Review Unit within three months of receiving the insurer’s decision.
Once an Application for Review has been lodged, the regulator is required to make a decision on the review within 25 business days. In some circumstances an extension may be granted.
When the Workers' Compensation Regulator have made a decision on the review application they will notify you within 10 business days.
If an Application for Review is unsuccessful, you can lodge an appeals with the Queensland Industrial Relations Commission. An appeal must be lodged within 20 days of receiving the Regulator’s decision.