Receiving and managing claims

When a worker completes and provides to you a Workers Compensation Claim Form accompanied by a First Certificate of Capacity, you have seven days to pass the documents to your insurer. You should make copies of these forms to provide to your worker, and for your own records.

It is not your decision to accept liability for the claim. Your insurer must assess the claim and advise you and the injured worker of their decision, in writing, within 14 days of receiving the claim. The advice must indicate whether it is accepted, declined or deferred.

Claims that involve travel

An injured worker is entitled to choose their own medical practitioner for diagnosis and treatment.

An injured worker cannot be required to attend medical appointments arranged by you or your insurer more than once every two weeks and only during reasonable hours.

If you would like a second opinion, you can request a medical review through your insurer.

A worker also cannot be required to see more than three medical practitioners who are specialists in the same field.

An employer cannot insist on being present at an injured worker’s medical appointment.

If a worker’s claim is accepted, their medical bills can usually be forwarded straight to the insurer for payment.

Prior to commencing any treatment, the worker should be advised to check with your insurer that any proposed treatments will be covered and costs reimbursed.

For more information on medical examinations, see Information Sheet 29.

Your insurance policy will detail what you can expect from your insurer. The best way you can assist your insurer is by immediately providing them with any relevant information you obtain regarding an injured worker. You should involve them as soon as possible after the injury occurs.

Getting feedback from your insurer

Ask your insurer for feedback regarding all claims, and consider arranging regular meetings. You can expect your insurer to inform you of the following:

• the cost of any claims made on your policy at least once a year
• any dispute referred to the Workers Compensation Conciliation Service and the outcomes of each stage of the dispute
• the renewal date for your policy.

The Workers Compensation and Injury Management Act 2023 (the Act) introduces a new obligation on employers to make provisional payments of income compensation and medical and health expenses if a deferred decision notice was initially given and the insurer has not given a liability decision notice before the provisional payments day (28 days from the date the insurer receives the claim). The Act also provides for claims to be ‘taken to have being accepted’ if a liability decision notice or deferred decision notice is not given and when required by the Act.

Insurers must give you either a liability decision notice or a deferred decision notice within 14 days after they have received the claim. If neither of these notices are given within 14 days, liability is taken to be accepted and employers are to commence weekly payments.

While the claim is being assessed If the claim is accepted

It is a fundamental principle of workers compensation that once an entitlement to income compensation is established and payments commence the payments cannot be reduced, suspended or discontinued, except in accordance with the Act.

When can a worker’s income compensation be reduced or ceased?

A worker’s income compensation can be reduced or ceased when in compliance with the Act (e.g. step-down after 26 weeks or where the General Maximum Amount has been reached), when in compliance with a direction of a conciliator or an order of an arbitrator, or for one of the following reasons.

With the consent of the worker:

• the worker may consent to reduce or discontinue income compensation payments
• the worker’s consent must be given in a written notice in the approved form – Intention to reduce or discontinue income compensation – consent
• the form must include details as to whether income compensation is to be reduced or discontinued, the date of the action and the reason.

The worker has returned to work:

• the worker must be given written notice in the approved form – Intention to reduce or discontinue income compensation – return to work
• the form must include details as to whether income compensation is to be reduced or discontinued, the date of the action and the return-to-work details
• if the worker does not agree with the employer’s decision to reduce or cease income compensation payments the worker may make an application to WorkCover WA’s Conciliation and Arbitration Services.

Medical evidence:

• income compensation is reduced or ceased based on medical certificate (evidence) indicating the worker has total or partial capacity for work, or the incapacity is no longer a result of the injury
• the worker must be given written notice in the approved form – Intention to reduce or discontinue income compensation – medical evidence
• the employer must give a copy to the worker of the medical evidence relied upon to reduce or discontinue income compensation payments
• the worker will have 21 days after receiving the form and medical evidence to make an application to WorkCover WA’s Conciliation and Arbitration Services if the worker does not agree with the employer’s decision to reduce or cease income compensation payments
• if the worker makes an application to WorkCover WA’s Conciliation and Arbitration Services within 21 days the employer cannot reduce or discontinue income compensation payments until the dispute is finalised
• if the worker does not make an application to WorkCover WA’s Conciliation and Arbitration Services within 21 days the employer may proceed to reduce or discontinue income compensation payments.

If the worker is not residing in Western Australia:

• the worker must provide a declaration about their incapacity for work to the employer’s insurer or self-insurer at prescribed intervals (3 months)
• if the worker fails to provide a declaration in time, the employer’s insurer or self-insurer may suspend the worker’s income compensation payments subject to:
  • the worker being given a written warning notice reminding them of their obligations to provide the required declaration before the due date Non-resident worker – declaration warning notice
  • the notice must also warn the worker that the payment of income compensation will be suspended from a specific date if they fail to provide a declaration
  • the warning notice cannot be issued to the worker earlier than 14 days before the last day the worker has to provide a declaration
  • the date specified as the suspension date must be at least 14 days after the warning notice is given to the worker can cannot be earlier than the last day the worker must provide the declaration
• if suspended, the income compensation payments must recommence from the date the worker provides the required declaration
• if the worker believes their income compensation payments were unlawfully stopped, the worker may apply to have the matter determined by an arbitrator.

Worker in custody:

• payments of income compensation are suspended if the worker is in custody under a law of WA, or another state, or the Commonwealth, or the worker is otherwise serving a term of imprisonment
• the employer must have written confirmation from the relevant government authority of the facts relevant to the worker being in custody or serving a term of imprisonment and this must be provided in the approve form Custody or imprisonment notice
• if suspended, the income compensation payments will be required to recommence from the date the worker is no longer in custody or serving a term of imprisonment
• if the worker believes their income compensation payments were unlawfully stopped, the worker may apply to have the matter determined by an arbitrator.

Employers must keep an injured worker’s position available (where reasonably practicable) for 12 months from the day the worker is entitled to receive weekly payments.

If your injured worker attains partial or total capacity to work during this time, you must provide their original position (where reasonably practicable), or another of equal status and pay for which they are qualified and capable of performing.

Intention to dismiss the worker

During the 12-month period, if you intend to dismiss your injured worker, 28 days’ notice of that intention must be given to them in the approved form, Intention to dismiss worker notice.

If your worker is in receipt of weekly payments at the time of dismissal, they will continue to receive statutory weekly payments and medical/related benefits.

Returning to work is the outcome you, your injured worker and their doctor work towards. In some cases, an injured worker may be left with a permanent impairment or incapacity for work which entitles them to a lump sum payment to finalise their workers compensation claim.

In order to access certain benefits or settlements, or pursue common law damages, it may be necessary for your injured worker to obtain an impairment assessment from an approved permanent impairment assessor of their choice.

Impairment assessments are usually required when you (or your insurer) and your injured worker have not agreed on a level of impairment.

What is an approved permanent impairment assessor? How the worker gets an assessment