Published: 27 July 2017
Author: Ryan Carlisle Thomas

WorkCover and TAC leaving injured to wait longer without income

Key points

• Unacceptable delays in WorkCover or TAC payments to the injured are on the rise
• Care should be taken when filling in WorkCover claim forms in order to avoid an insurer’s delaying tactics
• Should you be thrown off payments for no good reason, get legal advice

The injured are waiting longer for income payments despite having had their claims accepted by WorkCover and TAC. That’s our experience, as more clients turn to us to pressure these authorities and their insurers to pay clients what they are entitled to.

Genuinely injured people who are unable to work are having to wait longer for their income payments to start, or are having their payments suspended for weeks and sometimes months while insurers dither. In the meantime, families are often left with mounting debts as household expenses continue.

It’s completely unacceptable and needs to be addressed.

How WorkCover insurers delay claims

Legislation requires that injured workers submit certificates of capacity, which are required to be signed by workers (declaring whether or not they have earned any income during the period on the certificate) before they are submitted to the insurer.

Once compliant certificates have been sent to the insurer, the insurer or self-insurer must make weekly payments to workers before the expiry of seven days after the end of the week in which the claim is lodged. For example, if a worker submits a certificate of capacity, the insurer must make the weekly payment for week one, by no later than the end of week two of those 28 days on the certificate, provided the certificate was submitted at the beginning of that week one.

Unfortunately, some insurers are withholding payments on the basis that they wish to make sure that the incapacity for work continues to be relevant to the injuries for which the claim was accepted.

Or, because the diagnosis recorded by the treating doctor does is not exactly the same as the one that is in the original claim form.

Sometimes also they have their own “independent” doctor dispute the original diagnosis.

The problem is that the injured person can be left in limbo while insurer makes up their mind. 

The law on this matter is clear.

Insurers and self-insurers cannot withhold weekly payments on accepted claims unless they actually make a decision to reduce or terminate those payments. To reduce or terminate those entitlements, it is necessary for them to have supportive evidence.

Practical advice on filling in claim forms

These are some other points that injured workers should keep in mind when filling in their claim forms.

Workers cannot be considered medical experts and so what you record on your claim form cannot be held against you unless it is plainly wrong or different. For example, you are claiming benefits for time off work for a shoulder injury when your claim has been accepted for a knee injury.

To this end, we encourage workers when filling out their claim forms to be as general as possible. For example, if you have suffered a rotator cuff tear in your right shoulder, you should record “right shoulder” on your claim form. Unfortunately, if you record a “right rotator cuff tear” on the claim form, and the insurer gets a medical opinion to suggest that you have suffered a strain only, then there is a chance the claim will get rejected. The less detail the better. 

If your injury occurred over a period of time (and not on a particular day), you should say so on the claim form. The form offers only space for a date, but do not be under the presumption that you can only record a date; write “over the course of my employment” or “over the course of the last X days/months/years”.

If the claim ever gets rejected with a definite singular date, a further claim may need to be lodged which may delay any dispute about any rejection(s) or termination(s).

What people facing WorkCover payment delays can do

If you have submitted compliant certificates to the WorkCover insurer or self-insurer and have not received payments for a number of weeks, we encourage you to seek early legal advice or make a request for conciliation by completing this form and sending it to the Accident Compensation Conciliation Service.

If you require further advice or help, your lawyer should help you. In my experience, I find that clients do finally receive their payments.

TAC also delaying claims

Like WorkCover insurers, some of our clients have also faced significant and unnecessary delays in the processing of their claims and benefits.

One in particular has been forced to live off less than half of what his pre-accident weekly earnings (‘PAWE’) should have been calculated at for 6 months as the Transport Accident Commission is yet to finalise their calculations of this client’s PAWE. When all relevant information has been provided to TAC, there is no reason for such a delay.

There appears to be little appreciation of what claimants are being put through while waiting for their payments.

Summary

While genuinely injured people can take some precautions in order to avoid delays or suspension of their weekly payments, the onus is on WorkCover and the TAC to address the faults in the system.

The TAC and some WorkCover insurers are implementing new ways for the injured with accepted claims to submit certificates and medical expenses and we encourage those with access to take up the opportunity and use these new apps and online forms.

It’s hoped that by doing so, the chances of certificates being “lost” can be limited.

Previous Page