Declined claim

Reasons for disputes

Disputes can occur where the insurer:

• does not consider you a ‘worker’ under the legislation
• believes your employment did not substantially contribute to your injury
• determines the medical or related treatment, hospital treatment, ambulance service or workplace rehabilitation service (treatment or service) is not 'reasonable and necessary'.

Our Medical, hospital and rehabilitation expenses page explains the rules that apply to reasonable and necessary treatment or service expenses.

Request a review by the insurer

You can request that the insurer review the decision. In your request, include any additional information that may help. The insurer must respond in writing within 14 days, either overturning, modifying or maintaining the original decision. If they miss attaching all relevant documents, they must correct this as soon as possible.

Contact the Independent Review Office

The Independent Review Office (IRO) provides independent complaint and review services for workers compensation matters within NSW. You can contact the IRO if you have a complaint about how your insurer has handled your claim, including your claim being denied, and you have been unable to resolve the issue directly with your insurer. The IRO will review your complaint, engage with your insurer, review your claim, work with your insurer to address the issues and confirm what actions need to be undertaken to resolve your complaint.

You can contact the IRO on 13 94 76, by email complaints@iro.nsw.gov.au or online at iro.nsw.gov.au/contact-us-about-your-insurer.

Apply to the Personal Injury Commission

If you are dissatisfied with the insurer’s decision or not seeking a review by the insurer, you can apply to the Personal Injury Commission (PIC) to resolve the dispute. this Independent Tribunal helps resolve workers compensation disputes, including disputes about:

• work capacity decisions
• weekly payments and compensation
• medical, hospital and related expenses
• permanent impairment compensation
• compensation for damage to personal property
• compensation for domestic assistance.

The procedure varies based on the type of matter that is in dispute.

Contact the PIC on 1800 742 679 between 8:30am – 5:00pm Monday – Friday (except public holidays).