What to do when insurance refuses to pay for treatment of a work-related injury (even if liability has been accepted).

It can be incredibly frustrating to have the insurer accept liability for your work injury claim but then delay or refuse to pay for the treatment you need. At a time when your focus should be on recovery, dealing with uncertainty about your access to medical care can add significant stress. We break down the steps if you ever find yourself in this situation and go through your

available options to help you get the treatment you need.

In the first instance, any treatment that you require as a result of your work-related injury must be recorded by your treating General Practitioner (GP) on your SIRA certificate of capacity. 

The SIRA certificate of capacity is used in the NSW Workers Compensation Scheme to provide details regarding a worker’s injury or illness, their capacity to work, and the kind of treatment required for a sustainable recovery or return to work.

In addition, for any newly recommended treatment, it may be helpful for your GP to prepare a letter to the insurer briefly outlining why you need the treatment.

You must ensure that you or your GP sends the request to the insurer, who then has 21 days within which to approve or dispute the treatment.

It is a good idea to follow up with the insurer if you haven’t received approval within 14 days, preferably in writing (such as an email), and keep a record of it.

If the insurer does not approve your treatment within 21 days, you can contact the Independent Review Office (IRO) for assistance.

IRO provides a free Complaints Service to injured workers, which will liaise directly with the insurer on your behalf and can be accessed via the IRO website at: iro.nsw.gov.au

The IRO Complaints Service will either secure the insurer’s approval for the treatment you require or work with the insurer to make an official decision about the treatment. If the official decision does not reflect your desired outcome, you can seek immediate legal assistance to overturn the insurer’s decision.

Our Personal Injury team, including Elizabeth McDonald, Lawyer and Accredited Specialist in Personal Injury Law, is here to guide you through every stage of a work injury claim. If you are dissatisfied with an insurer’s decision, we can help dispute it to pursue the injury-related medical treatment you require.

Disclaimer: This article provides general information only and should not be considered legal advice. Outcomes for work-related personal claims depend on the specific circumstances of each case. You should obtain independent legal advice before acting on any information contained in this article.