Fact Sheet 13 - Workers compensation claims and the Victorian Ombudsman

In Victoria, WorkSafe Victoria administers the workers compensation scheme for people injured at work. WorkSafe engages five insurance agents to manage and process claims. Some employers in Victoria are self-insured and manage their own workers compensation claims.

Who is the Victorian Ombudsman?

The Victorian Ombudsman takes complaints about the administrative actions and decisions of state government departments, agencies and local councils (and bodies acting on their behalf).

We can look at whether their actions were lawful, reasonable and fair, and whether they are compatible with the human rights in the Charter of Human Rights and Responsibilities Act 1996 (Vic). We are independent and impartial and our service is free.

We can take complaints about WorkSafe, self-insurers and the five insurance agents. These are Allianz, CGU, EML, Gallagher Bassett and Xchanging. The Ombudsman can also look at complaints about administrative issues involving the Accident Compensation Conciliation Service (ACCS) and WorkCover Assist.

Making a complaint to the Ombudsman

Claims decisions

People who want to dispute a decision made on their WorkCover claim (eg payments being terminated or a claim rejected) can contact the Victorian Ombudsman for advice. However, importantly, there is an established process for people to dispute claims decisions, which includes conciliation through the Accident Compensation Conciliation Service (ACCS) and then court. This is the most appropriate way to dispute decisions in many cases, including where there is a dispute of the facts. Workers can also ask an agent to conduct an internal review of its decision, before going to conciliation.

There are no hard and fast rules about whether the Ombudsman becomes involved. We may be able to assist where:

  • There was not enough evidence to support the decision.
  • The agent did not consider evidence to support the decision or selectively used evidence (eg they relied on one medical report, but ignored several other relevant reports).
  • There is evidence that the agent/WorkSafe made a mistake. This can include not following the law or WorkSafe's Claims Manual.

Service delivery issues

If you have concerns about 'service delivery' issues (eg delayed/late payments or a failure to respond to you), you should first complain to the complaints department of the agent/self-insurer managing your claim. If you are unable to resolve the issue within a reasonable period of time or there is a clear mistake, the Ombudsman may be able to assist you.

Complaints to WorkSafe

WorkSafe can take complaints about Independent Medical Examiners (IMEs) and Occupational Rehabilitation providers. Contact WorkSafe first and you may contact the Ombudsman if you are dissatisfied with WorkSafe's handling of your concerns.  

 

Please note: This document is intended as a guide only. For this reason the information contained herein should not be relied on as legal advice or regarded as a substitute for legal advice in individual cases. To the maximum extent permitted by the law, The Victorian Ombudsman is not liable to you for any loss or damage suffered as a result of reliance on this document. For the most up-to-date versions of cited Acts, please refer to www.legislation.vic.gov.au.

 
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Contact Details

Victorian Ombudsman
Level 2
570 Bourke Street
Melbourne VIC 3000
Phone                     03 9613 6222
Toll free                  1800 806 314
Fax                         03 9602 4761
TTY                        133 677 or
                               1800 555 677
Interpreter service  131 450