Claims

The Workers' Compensation Claims Process

ClaimsGateway

22 Oct 26

•

min read

When a worker is injured, the employer records the injury, notifies its workers' compensation insurer or agent within the state's deadline, and passes on the claim. The insurer decides liability and pays entitlements, while the employer supports return to work. Each state runs its own scheme with its own deadlines, and self-insurers do the insurer's work themselves.

This article is general information, not legal or compliance advice. Check the current text of the code, standard or legislation, and take advice for your situation.

Key takeaways

According to SIRA, a New South Wales employer must make sure its insurer is notified within 48 hours of becoming aware of a work-related injury.
In NSW, according to SIRA, the insurer must start provisional weekly payments within 7 days of initial notification, unless it has a reasonable excuse.
In Queensland, an employer must report an injury to WorkCover within eight business days of being notified, and late reporting is an offence.
According to Safe Work Australia, there were 146,700 serious workers' compensation claims in Australia in 2023-24.
Each state and the Commonwealth's Comcare scheme sets its own process, so the steps are similar but the deadlines differ.

What is the workers' compensation claims process in brief?

The process has six steps: the injury is reported and recorded, the employer notifies its insurer or scheme agent, the worker lodges a claim, the insurer decides liability, entitlements are paid, and the worker returns to work before the claim closes. The employer has duties at every step, even when the insurer runs the claim.

Speed matters early. Prompt notification lets the insurer start support quickly, and in some states it triggers provisional payments before liability is decided. Late notification can be an offence and can delay the worker's treatment.

Return to work runs alongside the claim. Employers are expected to provide suitable duties and support recovery, and the return-to-work plan is often what decides how long a claim lasts.

What are the steps, one by one?

The steps run from injury to closure. Report and record the injury, notify the insurer within the deadline, help the worker lodge the claim, cooperate while the insurer decides liability, pay or pass on weekly payments as directed, and support return to work until the claim closes. Each state sets its own deadlines.

Report and record. The worker reports the injury, and the employer records it in its register of injuries. Serious injuries, illnesses and dangerous incidents must also be notified to the WHS regulator immediately.
Notify the insurer. The employer notifies its workers' compensation insurer or agent within the state's deadline. In NSW, according to SIRA, that is within 48 hours of becoming aware of the injury.
Lodge the claim. The worker completes a claim form, usually with a certificate of capacity from their doctor. The employer forwards it as required.
Decide liability. The insurer assesses the claim. In NSW, according to SIRA, it has 21 days from receiving the claim form to accept or dispute liability.
Pay entitlements. Weekly payments and medical costs are paid while the claim is accepted. Some employers pay weekly amounts through payroll and are reimbursed.
Return to work and close. The employer, worker, doctor and insurer agree a return-to-work plan. The claim closes when entitlements end or the worker recovers.

How does the process differ by state?

Each state and territory runs its own workers' compensation scheme, and the Commonwealth runs Comcare for its employees and licensed corporations. The steps are similar everywhere, but deadlines, forms and who manages claims differ. Employers working in several states need to follow each state's rules for workers employed there.

New South Wales. Who manages most claims: Insurers, including icare, regulated by SIRA; An employer deadline to know: Notify the insurer within 48 hours of becoming aware of an injury.
Victoria. Who manages most claims: WorkSafe Victoria's agents; An employer deadline to know: Forward the claim to the agent within 10 calendar days of receiving it, for a physical injury.
Queensland. Who manages most claims: WorkCover Queensland; An employer deadline to know: Report the injury to WorkCover within eight business days of being notified.
Commonwealth. Who manages most claims: Comcare and licensed self-insurers; An employer deadline to know: Set by the Comcare scheme for its employers.

Other states and territories run their own schemes with their own deadlines. Check the regulator for each place you employ people. The workers' compensation claims software covers systems that track these deadlines.

What changes for self-insurers?

A licensed self-insurer does the insurer's work itself: it decides liability, pays entitlements, manages return to work and keeps the records, under the regulator's standards. The steps are the same, but the self-insurer owns all of them. It must also meet the licence's requirements for resources, reinsurance and claims capability.

According to SIRA, a New South Wales self-insurer must have the resources to meet its obligations and hold reinsurance against insolvency. Other states and Comcare set similar conditions. As a result, self-insurance suits large employers with the scale and expertise to run claims well.

The work is continuous. According to Safe Work Australia, there were 146,700 serious workers' compensation claims across Australia in 2023-24. A large self-insurer handles its share of those every week. The self-insured vs fully insured explains the difference.

What records and systems does the process need?

Every employer needs a register of injuries and a way to track each claim's deadlines and return-to-work plan. Self-insurers and large employers also need a claims system that records decisions, payments and correspondence, because regulators audit those records. The larger the workforce, the harder this is to do in spreadsheets.

Deadlines are the main risk. Missing a notification deadline can be an offence, and delays harm the worker's recovery. A system that starts the clock when the injury is reported helps.

ClaimsGateway (claimsgateway.com) builds cloud claims software for insurers, TPAs and self-insured organisations, handling injury and workers' compensation claims among others. The ClaimsGateway self-insured and mutuals page describes its approach. Employers whose insurer runs every claim may need only a well-kept injury register.

Frequently asked questions

How long does a workers' compensation claim take?

It depends on the injury and the state. In NSW, the insurer has 21 days from receiving the claim form to accept or dispute liability, and provisional weekly payments can start within 7 days of notification. Simple claims may close within weeks, while serious injuries can take months or years.

When must an employer notify the insurer?

It depends on the state. In NSW, according to SIRA, the employer must make sure the insurer is notified within 48 hours of becoming aware of a work-related injury. In Queensland, the employer must report to WorkCover within eight business days. Check your state's regulator for the rule that applies.

Who pays while a claim is decided?

In some states, the insurer can begin provisional payments before liability is decided. In NSW, according to SIRA, the insurer must start provisional weekly payments within 7 days of initial notification unless it has a reasonable excuse. Accepting provisional liability is not an admission of liability.

What is return to work?

Return to work is the process of helping an injured worker get back to work safely, often through suitable duties while they recover. The employer, worker, treating doctor and insurer agree a plan. Employers have legal obligations to support return to work, which vary by state.

Is the process the same in every state?

No. Each state and territory runs its own scheme, and the Commonwealth runs Comcare. The steps are similar, but deadlines, forms, entitlements and who manages claims differ. Employers with staff in several states must follow each state's rules for the workers employed there.

About the author

ClaimsGateway builds cloud claims management software for insurers, underwriting agencies, brokers, TPAs and self-insured organisations in Australia and New Zealand. Every regulator figure in this article links to its source, and every vendor fact was checked on the vendor's own site on the date shown.