If your claim for compensation (weekly payments or a medical cost) is rejected, first talk to your case manager about it. If you are still not satisfied, you can lodge a dispute at the SA Workers Compensation Tribunal (the Tribunal) by filing a Notice of dispute. You have one month from the date you receive the decision from your case manager to do this. This form is available from the Tribunal's website.

Sophie develops an illness that she feels is related to her work. She visits her GP and receives a Prescribed Medical Certificate, and then lodges a claim for compensation. After 15 days, she hears that her claim has been rejected. What can Sophie do?

Sophie should firstly discuss the claim with the claims agent to discover why the claim was not accepted. If she is unhappy with the decision and wants to pursue it, she is entitled to lodge a Notice of Dispute with the Workers Compensation Tribunal within one month of receiving the decision. The decision will be internally reviewed by the claims agent. If the decision is not changed, she can pursue the dispute through conciliation firstly, then arbitration and finally judicial determination if necessary. Sophie can seek assistance and representation from her union or a solicitor.

Once you lodge a Notice of dispute in the Tribunal, the Tribunal directs Employers Mutual or the self-insured employer to reconsider its decision. If the decision remains unchanged, or you lodge a Notice of dissatisfaction with reconsideration because you are unhappy with a variation of the decision, the Tribunal will allocate a conciliation officer who will initially arrange a dispute management conference. This is an informal meeting, involving the parties in the dispute and their representatives.

If not resolved before or at the dispute management conference, the dispute will proceed to a compulsory conciliation conference where the parties try to negotiate an outcome that is acceptable to everyone. Once all parties agree, consent orders are prepared, signed by all the parties and sealed by the Tribunal.

If the matter cannot be resolved at conciliation, the dispute will be referred to judicial determination, which is a formal hearing before a single presidential member of the Tribunal. Legal representation is highly recommended. If a dispute gets to this stage, a decision will be made by the presidential member which is final, except in limited circumstances (ie, questions of law).

An appeal can be lodged to the Full Bench of the Tribunal only on a question of law. The Full Bench of the Tribunal may refer a question for the opinion of the Full Court of the Supreme Court. An appeal can also be lodged from a decision of the Full Bench of the Tribunal to the Full Court of the Supreme Court on a question of law, but only with the permission of the Supreme Court.

Medical Panels SA is an independent body specifically set up to deal with workers compensation medical disputes. When a dispute involves opposing medical opinions, for example, about your injury or capacity for work, medical questions will be referred to, and an opinion provided, by a medical panel. A medical panel is able to give an opinion on any medical question referred to it under the Act. A medical panel will form its opinion within 60 days of a referral. You will receive written confirmation of this opinion, which you may discuss with your case manager.

Note: Medical panels come into effect from 1 April 2009.

The case manager generally must make a decision about whether a claim is accepted or rejected within 10 business days of receiving the claim (unless weekly payments and medical costs under provisional liability have already started. Provisional weekly payments normally start within seven calendar days).

If a claim has not been determined within a reasonable period (which will depend on the circumstances), you or your employer can apply to the Workers Compensation Tribunal for what is called an 'expedited decision'. This means that the Tribunal gives your claims agent a time limit to make a decision. If this doesn’t happen, the Tribunal may determine the claim. This form is available from the Tribunal's website.

If you are not satisfied with any aspect of the management of your claim, your first point of call should always be your case manager. Talk to them or their team leader about the reasons you are unhappy.

Most decisions made about your claim are reviewable by the Workers Compensation Tribunal; each letter about a decision from your case manager should include your review rights and you have one month to lodge a Notice of dispute with the Tribunal.

You can also contact WorkCover on 13 18 55 and ask to speak to our Service Improvement Unit (or write to the unit at WorkCover, GPO Box 2668 Adelaide 5001 or email info@workcover.com). Alternatively you can raise your concerns with the WorkCover Ombudsman who runs an independent office set up to investigate complaints relating to the operation of the WorkCover Scheme. The Ombudsman reports to the Minister for Industrial Relations. To contact the Office of the WorkCover Ombudsman phone (08) 8463 6593, or toll free on 1800 195 202 or visit www.wcombudsmansa.com.au.

If you are having difficulties with your employer, for example, they are not providing suitable work or not cooperating with your return to work plan or instructions on your WorkCover Medical Certificate, discuss this as a priority with your case manager.

Your employer has an obligation to comply with section 58B of the Act, which says they must provide suitable employment, and make every reasonable effort to help your return to work under a plan. They can have a supplementary levy imposed or be prosecuted for not doing this. See the FAQs listed at the back of this booklet for more information.

Under Freedom of Information (FOI) laws, you can apply to see or ask for a copy of your claim and other records. There may be some documents that this does not apply to. There are prescribed fees that apply, which may be waived in certain circumstances. You can also apply under section 107B of the Act for access to your claim file (this is free). Our website has the forms needed for this process (browse the documents A-Z and see under 'F' and 'S').

To apply for access, visit the following links:

S107B Application for Access [439.83 KB]

Freedom of Information - Application for access [345.79KB]

Freedom of Information - Application for Review of Determination [341.71KB]

Freedom of Information Fees and Charges [60.4KB]

The Act is very specific about disclosure of information. WorkCover, Employers Mutual and self-insured employers have strict policies about who is entitled to see claimant information. Other providers are also bound by the Act and the Federal Privacy Act.

The delivery of advocacy and representation services on behalf of injured workers is provided by SA Unions. Advocacy services for claimants who are in dispute with WorkCover are provided by individual unions for their members. Non-union members may also seek legal advice or representation from lawyers or SA Unions.

WorkCover provides information to injured workers, employers and others about entitlements, claim decisions, disputes and Scheme navigation. Call our Service Centre on 13 18 55 for assistance. If the issue is not resolved you may wish to register a formal complaint with WorkCover. You can use this website to contact us to make a complaint.