Key References & Legislation
What to do if your claim is disputed
- • Check for a section 78 notice or any written insurer decision explaining the reason for refusal.
- • Confirm whether any review or dispute deadline applies to the type of decision you received.
- • Gather your medical evidence, especially current Certificates of Capacity, specialist reports, and wage records.
- • Get advice quickly. Many dispute costs are funded through IRO, so delay usually causes more damage than the legal process itself.
Quick answer: what should you do first if your workers comp claim is disputed?
Start with the written decision (usually a section 78 notice), identify the exact dispute type, then build targeted evidence for that reason—rather than arguing generally. Most failed disputes are evidence-and-pathway failures, not "bad luck" outcomes.
- • Save the notice and deadline date the same day.
- • Update Certificates of Capacity and specialist evidence to match the insurer's stated reason.
- • Check whether liability, work capacity, PIAWE, and treatment disputes are running in parallel.
- • Use the correct review path quickly (internal review, IRO-supported legal pathway, or PIC process).
Why insurers dispute claims
Insurers often issue a section 78 notice or similar written decision to deny liability, reduce weekly payments, or refuse treatment. The stated reason matters because it usually dictates what evidence will fix the problem and which review path applies.
If the dispute relies on insurer medical evidence, compare it with our guides to handling an independent medical exam (IME) and challenging an unfair IME report. If the issue is really a payment-rate problem, use the PIAWE calculation guide and the recalculation request guide.
- No work-related injuryThe insurer says the injury did not happen at work or that the symptoms are really a pre-existing condition.
- Employment was not a substantial contributing factorThis usually appears in causation disputes involving gradual injuries, aggravations, or psychological claims.
- Capacity for workThe insurer says you are fit for “suitable employment” even if your own doctor disagrees or the proposed job is unrealistic.
- Treatment is not reasonably necessaryThe insurer refuses scans, surgery, psychology, rehab, pain treatment, or specialist referrals by reframing the issue as unnecessary care.
Common dispute types
1. Liability disputes
The insurer denies the whole claim. You usually need to prove the injury happened in the course of employment and that the medical evidence supports the connection to work.
Learn about denied claims →2. Work-capacity disputes
The insurer reduces your weekly payments because it says you can work more hours or earn wages in another role.
3. Medical and treatment disputes
The insurer refuses to fund a scan, specialist review, rehab plan, psychology treatment, surgery, or other medical expense.
4. Causation and pre-existing condition disputes
The insurer says your symptoms were already there before work or that work was not a substantial contributing factor. This is common in back, neck, shoulder, and psychological matters.
What usually goes wrong before a dispute becomes serious
The real damage often happens before the formal dispute is filed. Workers spend days arguing with claims officers by phone while the insurer builds a paper trail around weak certificates, underpaid wages, or a one-sided IME opinion. Fixing the evidence early usually matters more than arguing loudly.
1. The dispute is reframed as a payment or capacity issue
What looks like a simple underpayment or ongoing entitlement issue is often reframed as a work-capacity decision, which changes the urgency and the review pathway.
2. The wage evidence is never cleaned up
Underpaid PIAWE can sit in the background while the insurer pushes a broader dispute narrative. If wages were wrong from the start, the financial pressure gets worse every week.
3. Thin medical evidence gives the insurer room to move
Generic certificates rarely beat a detailed insurer IME. The treating team usually needs to address causation, restrictions, treatment need, and work capacity directly.
4. Bigger threshold issues are missed
Some disputes are a warning sign that the claim is shifting toward 130-week eligibility, the section 39 cutoff, WPI threshold strategy, or possible work injury damages.
How to choose the right dispute path
The right next step depends less on your frustration level and more on what the insurer has actually decided. Start by matching the dispute to the decision type, then build the evidence around that issue.
Claim denied
What to do when the insurer denies the whole claim and disputes liability from the outset.
Section 78 notice
How to respond when the insurer issues a formal liability notice with reasons for refusal or reduction.
Work capacity decisions
How to challenge payment cuts based on suitable employment, earnings capacity, or capacity classifications.
Weekly payments stopped
Urgent steps when wages are reduced or cut off after a review or insurer decision.
Treatment denied
How to deal with treatment refusals involving scans, rehab, specialist care, and ongoing management.
Surgery denied
What usually matters when the insurer says surgery is not reasonably necessary.
Pre-existing condition disputes
How insurers use degeneration and prior symptoms to challenge causation and entitlement.
PIC disputes process
The formal Personal Injury Commission pathway for statutory disputes when review and negotiation are not enough.
Frequently asked questions
Can I still see my doctor if the claim is disputed?
Yes. Even if the insurer stops paying for treatment during a dispute, you should usually continue seeing your GP and keeping your Certificates of Capacity current. Those records often become essential evidence.
What is a Section 78 Notice?
A section 78 notice is the formal document an insurer must send if it disputes liability, reduces benefits, or refuses part of the claim. It should explain the decision, the reasons for it, and the material the insurer relied on.
What should I do in the first 48 hours after a dispute notice?
Save the full notice pack (including attachments), confirm the deadline date, update your Certificate of Capacity to directly address the insurer's reasons, and gather wage/treatment records. Fast evidence alignment in the first 48 hours usually prevents avoidable pathway errors later.
How much does it cost to dispute a workers compensation decision?
For many NSW workers compensation disputes, legal costs are funded through IRO. Where funding applies, the worker usually does not pay their lawyer directly for the dispute work.
How long do I have to challenge a dispute decision?
Time limits can vary depending on the type of dispute, but delay is risky. The earlier you respond, the easier it usually is to preserve medical evidence, wage records, and the correct review pathway.
Keep these dispute guides open
What to do next
A dispute is a challenge, not a dead end. Many denied or reduced claims improve once the right medical, wage, and threshold evidence is gathered and pushed through the correct review path.