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Claims management guide

Resolving complaints and disputes

Dispute resolution pathways

Flowchart showing dispute resolution pathways before and after 1 January 2019. Before 1 January 2019 there were 2 pathways for where the insurer fails to determine a claim or makes a decision that the claimant disagrees with. The chart shows that if it is a work capacity decision: the insurer issues a section 54 notice, then the claimant can request an internal review by the insurer, then proceed to a merit review by SIRA, then a procedural review by WIRO, concluding in a judicial review in the Supreme Court. The chart also shows that for all other workers compensation disputes: the insurer issues a section 74 notice, then disputes proceed to the Workers Compensation Commission (with its internal appeal avenues, to Presidential member or Medical Appeal Panel), concluding in an appeal to the NSW Court of Appeal. From 1 January 2019, where an insurer fails to determine a claim or makes a decision that the claimant disagrees with, there is a single dispute pathway. The chart shows that in all cases: the insurer issues a section 78 decision notice, with an optional internal review by the insurer (mandatory if requested by claimant), then the claimant can dispute the decision in the Workers Compensation Commission (with its internal appeal avenues, to the President member or Medical Appeal Panel), concluding in an appeal to the NSW Court of Appeal.

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