If you disagree with the insurer’s decision on your claim, you can lodge an Application for Review with the Regulator. A review is an independent administrative process conducted by a Review Officer from the Regulator who will make a decision on the review based on the information contained on the claim file, information provided by you for the review, and information that may be provided by an employer during the review process.
Insurer decisions that can be reviewed include:
- rejection or acceptance of a claim;
- termination, suspension, increase or decrease of a weekly benefit;
- refusal of an entitlement to certain expenses; and
- refusal to waive the time-frames involved in lodging a claim.
An Application for Review must be lodged within 3 months of receiving the insurer’s decision. A review decision may confirm or overturn an insurer’s decision or may direct the insurer to seek further information and make a fresh decision on a claim.
Read the insurer’s reasons for its decision on your claim.
If the insurer has not provided its reasons in writing, you have 20 business days to request the insurer provide you with written reasons. It is important to understand how the insurer reached its decision as your Application for Review will need to demonstrate why you believe the decision is not correct.
Considering the grounds on which you are requesting a review of the insurer’s decision and the information and documents you have or may need to gather to substantiate your grounds.
Obtain and Application for Review from the Regulator. Set out the reasons why you think the insurer’s decision was incorrect. Refer to the information you may be attaching to your application and state why it is relevant. (It may be necessary to attach additional pages to your Application for Review.)
Lodge the completed Application for Review and attachments with the Regulator within 3 months of receiving the insurer’s decision.
On receipt of an Application for Review, the Regulator will appoint a Review Officer who will obtain your claim file, review the information provided with the Application for Review or during the review process. The Review Officer does not re-investigate or gather further statements.
As part of the review process an inured worker has a Right of Appearance. This gives you an opportunity to speak to the Review Officer and provide any new relevant information.
The Regulator will make a decision on a review application within 25 business days and notify you within 10 business days of the decision. If the Regulator has been unable to make a decision within the 15 business days they will contact you.