Published: 25 July 2019
Author: Ryan Carlisle Thomas
What you need to know about WorkCover entitlements
This blog explains how the WorkCover system works in paying your medical bills and weekly payments while you’re off work. It also offers practical legal advice on time limits, surgery, and income replacement for injured workers.
How WorkCover works
You might be wondering how the WorkCover system works and I can tell you one thing for sure: it’s incredibly complicated and there are a lot of very difficult time limits. One good piece of advice is that it doesn't matter how soon you consult a lawyer; the earlier the better because there are some things that the insurers might impose on you pretty early on in the life cycle of your claim that could cause you grief.
For instance, insurers can have investigators follow you and put you under surveillance to confirm whether you've indeed been injured in the way that your claim form says that you have.
So there are things like that that you might just want to check with lawyers in terms of your rights.
Initial medical expenses
Generally speaking, if someone submits a WorkCover claim and it's been accepted, that person then has an entitlement to both reasonable medical and like expenses paid for by the WorkCover insurer. They also have an entitlement to be paid weekly payments in lieu of their former weekly wage.
In terms of the weekly payments the way they work is that you need to provide regular medical certificates to the insurer to demonstrate that you have an incapacity for work. Those medical certificates after your claim is initially accepted — usually you would get them for say a 28-day period at a time — you submit them to the insurer. What will happen once those medical certificates have been received is that for the first thirteen weeks after your injuries being sustained the WorkCover insurer will pay weekly payments to you as an injured worker at a rate of ninety five percent of your average pre-injury earnings.
That average includes regular shift allowances and overtime.
Calculating your weekly payments
There can be some disputation around how that figure is calculated so again it's a good idea if you do consult a lawyer early on in the life cycle of your claim so that we can double-check the figures and give you some advice about whether you’re being paid the correct amount.
After the first thirteen weeks from the date of your injury you then have a step down in the percentage your weekly payments are then paid at 80% of your former pre-injury wage. And that will remain subject to regular medical certificates being submitted and improved by the insurer — theoretically for the remainder up until 130 weeks post the date of your injury.
Ongoing medical expenses
Quite apart from the weekly payments proportion of someone's entitlements, it's important to remember that you also have an entitlement to reasonable medical and like expenses being reimbursed by the insurer.
You should absolutely make sure that you keep any receipts or invoices for any treatment, medication and travel that have been related to your injury and its treatment. Because once you submit those to the WorkCover insurer they should go through a process of checking off that those medical treatment expenses are reasonable, connected to the injury for which you're claiming WorkCover, and if they deem that they are then they'll reimburse those expenses.
As your injury and treatment progresses you may be referred to a specialist who might recommend that you undergo an MRI and perhaps surgery, or something like that.
For those big expensive items such as back surgery or knee surgery or something like that or a pain management course, the insurer will want to make sure by way of sending someone to an independent medical examination that those expenses are reasonable under the Act.
That's nothing to worry about most of the time if someone has been recommended by GP to see a specialist. If the specialist is of the opinion — who might be a surgeon or someone like that — that treatment is necessary, usually they will send a report to the WorkCover insurer requesting the treatment be paid for under WorkCover.
Generally speaking anything that's going to be recommended by an appropriately qualified medical specialist is going to be approved by the insurer. But for expensive items the insurer is always going to second-guess by sending you to an independent many examiner.
That examiner will then conduct an examination on you and will do report back to the WorkCover insurer and they will say whether they believe the treatment is reasonable and whether it's connected to the WorkCover incident or not.
In the event that it is, the WorkCover insurer will send a decision letter approving that funding and then you'll be able to book in and have your surgery or whatever the case may be, and WorkCover will pay the cost of that.