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How long does the insurer have to accept my claim?

How long does the insurer have to accept my claim?

Published on October 6, 2021 by David Jones and Dane TwohillDavid Jones and Dane Twohill

One of the most common questions that I am asked by an injured worker when providing them advice following a workplace injury is, “how long does the insurer have to decide whether they accept my claim?”. Whilst the insurer is required by law to make a decision to accept your claim or not within 21 days, it is often not as clear cut as that. Let me explain.

Making a claim

If you suffer an injury at work you should immediately notify your employer. If you require treatment or time off work as a result of the injury, you should also attend your general practitioner to obtain a Workers Compensation Certificate of Capacity (‘Workers Compensation Certificate’).

Once you have obtained a Workers Compensation Certificate you should then complete a Worker’s Injury Claim Form (‘claim form’) and provide a copy of both documents to your employer. You should also ensure you retain a copy of these documents for your records.

Following receipt of a Workers Compensation Certificate and/or claim form, your employer is required to provide them to their workers compensation insurer within seven (7) days (Section 264 of Workplace Injury Management and Workers Compensation Act (WIM) Act).

How long does the insurer have to accept or deny the claim?

The workers compensation insurer must make a decision as to whether they accept your workers compensation claim or not within 21 days (Sections 274 & 279 WIM Act).

If you are unable to work due to your injury, the insurer must commence provisional weekly payments of compensation within seven (7) days unless the insurer has a reasonable excuse for not commencing weekly payments (Section 267 WIM Act). If the insurer is investigating your claim and whether to accept liability, they must commence these payments on a provisional basis.

There are only certain reasonable excuses which the insurer can rely upon to refuse to commence provisional payments.

If an insurer refuses to commence provisional payments within 7 days it is important to obtain legal advice.

Delays in the insurer accepting claim

In my experience, it is not uncommon for insurers to take longer than the required 21 days to make a decision as to whether they accept a claim for workers compensation benefits.

Sadly I also see cases where an insurer will assert they have a ‘reasonable excuse’ not to commence provisional payments, causing severe financial hardship to injured workers at a time in their life when they are most vulnerable.

The Independent Review Office (‘IRO’) recently released a report into insurers’ delays in determining liability. Consistent with my experience, IRO reported that the most common complaints they receive from injured workers in relation to an insurers delay in making a decision as to whether the insurer accepts liability. In the sample reviewed by IRO, the delay ranged from a few days to over three months.

IRO made a number of recommendations including:

  1. Insurers consider the points raised in the IRO report to inform them of the causes of complaints about delays in determining liability and the opportunities to improve case management activities to reduce unnecessary complaints;
  2. Insurers review their case management systems and business processes to establish whether they accurately record and comply with statutory timeframes when determining claims and if not, rectify any deficiencies;
  3. The State Insurance Regulatory Authority (SIRA) consider the findings of the report and explore opportunities to improve standards and guidance with insurers.

If you have suffered an injury at work and have made a claim for workers compensation benefits, there are strict time limits which the insurer must comply with.

If the insurer has not made a decision to accept your claim within 21 days, or has refused to commence provisional payments within 7 days, you should seek further legal advice.

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