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 promptly. IRO funding may be available if an Approved Lawyer and the IRO are satisfied that the current funding criteria are met.
Overview: what should you do first if your workers comp claim is disputed?
Start with the written decision, identify the exact dispute type, and collect evidence that addresses the stated reasons. Do not assume every adverse decision is a section 78 notice or that every dispute uses the same review process.
- • Save the notice, attachments, and delivery details when received.
- • 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.
- • Confirm the available review path before any applicable deadline expires.
Why insurers dispute claims
An insurer may issue a section 78 notice when disputing liability for a claim or an aspect of it. Other decisions, including some weekly-payment and work-capacity changes, can use different notices. The stated reason and decision type determine what evidence and procedure may be relevant.
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.
- The statutory connection with employment is disputedThe required test depends on the injury type, cause, notification or claim date, and current legislation. A gradual disease, aggravation, physical injury, and primary psychological injury should not be treated as if they all use one test.
- 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.
Dispute document checklist
Use this checklist to preserve documents, identify the written reason, check any applicable time limit, and distinguish liability, payment, capacity, and treatment issues.
- 1As soon as practicable, save the full insurer decision pack, note the decision date, and list every attachment you received.
- 2Promptly identify whether updated treating evidence is needed to address the insurer’s stated medical or capacity reason.
- 3Collect wage records, treatment approvals, and employer communications early so liability, PIAWE, and work-capacity issues are not mixed together.
- 4Before any deadline expires, choose the right pathway, whether that is internal review, an assessment for ILARS funding, or a PIC application.
Evidence checklist before you challenge the insurer
A dispute usually turns on whether your evidence answers the insurer's reason directly. Before you challenge the decision, make sure your file covers the medical, wage, and procedural gaps that often decide NSW workers compensation disputes.
- • Current Certificates of Capacity that directly address causation, restrictions, and work capacity.
- • Specialist or treating doctor reports that explain why treatment remains reasonably necessary.
- • Payslips, rosters, overtime records, and allowances if weekly payments or PIAWE are in issue.
- • The insurer notice pack, including medical reports, investigation material, and any IME relied on by the insurer.
- • A simple chronology of phone calls, emails, certificates, treatment requests, and employer responses.
Common dispute types
1. Liability disputes
The insurer denies the whole claim. The evidence may need to address when and how the injury occurred, the applicable statutory connection with employment, and the medical diagnosis and causation opinion.
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 relies on earlier symptoms, degeneration, or another cause. The applicable causation test must be checked for the injury type and date rather than using one formula for every physical or psychological claim.
Records to check before choosing a dispute path
A written response should address the actual insurer decision. Check the certificate of capacity, wage records, treatment requests, IME material, and correspondence rather than relying only on telephone discussions.
1. The dispute is reframed as a payment or capacity issue
A payment change may arise from a PIAWE calculation, a work capacity decision, or another statutory rule. Identify the decision type because the available review process can differ.
2. The wage evidence is incomplete
A PIAWE dispute may require payslips, rosters, allowances, overtime, and relevant second-job records. Compare the insurer calculation with the records and current rules.
3. Medical evidence does not address the stated reason
A certificate of capacity may not answer every causation, treatment, or capacity issue. A treating report should address the relevant question and clinical basis where appropriate.
4. Different entitlement tests are combined
Weekly payments after particular periods, permanent impairment, serious-injury status, and work injury damages use different statutory requirements. Check the relevant rule for the actual entitlement, injury type, and claim history.
Common mistakes that weaken a dispute
A response may be less useful if it addresses the wrong decision, omits relevant documents, or relies on general assertions. These are common record and process problems to avoid.
- • Arguing by phone without sending targeted written evidence that matches the insurer’s stated reason.
- • Treating a payment-rate issue like a pure liability dispute, or vice versa, and missing the correct review path.
- • Letting an outdated Certificate of Capacity remain on file while the insurer relies on a newer IME or factual investigation.
- • Waiting too long to fix wage evidence, which can leave underpayments compounding while the dispute drags on.
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.
Employer will not report the injury
How to preserve notice evidence, identify the insurer and notify the claim directly when an employer does not act.
No witness to the work injury
Evidence that may support a claim when nobody directly saw the accident or the condition developed gradually.
No workplace incident report
How to prove notice and the work injury where the employer never completed its internal incident form.
Insurer delay or no decision
How to identify the overdue decision, preserve lodgement proof and choose the correct complaint or dispute pathway.
Section 78 notice
How to respond when the insurer issues a formal liability notice with reasons for refusal or reduction.
Claim accepted, then disputed later
How to distinguish provisional acceptance from full acceptance and identify what a later insurer notice actually disputes.
Work capacity decisions
How to challenge payment cuts based on suitable employment, earnings capacity, or capacity classifications.
Insurer ignoring psychological symptoms
How to respond when the insurer focuses on physical injury but ignores depression, anxiety, pain-related distress or treatment need.
Weekly payments stopped
What to check when weekly payments are reduced or stopped after a review or insurer decision.
Weekly-payment overpayment alleged
How to check the insurer calculation, recovery basis, consent and hardship issues before agreeing to repayment.
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.
WPI assessment or section 66 offer too low
How to distinguish a medical assessment issue from an offer calculation error and identify the correct review stage.
PIC disputes process
The formal Personal Injury Commission pathway for statutory disputes when review and negotiation are not enough.
No suitable duties
What to document when no suitable work is offered or the proposed duties conflict with certified restrictions.
Employment ends during a claim
How resignation, dismissal or redundancy may affect suitable duties and weekly-payment evidence without automatically ending the claim.
Employer closed or cannot be located
How to identify the legal employer, insurer and claim pathway when a business has closed, become insolvent or was uninsured.
Frequently asked questions
Can I still see my doctor if the claim is disputed?
You can continue to obtain medical care, but whether the insurer must pay for it depends on liability, the treatment claimed, and the decision in dispute. Keeping clinical records and Certificates of Capacity current may also be important evidence about diagnosis, treatment, and work capacity.
What is a Section 78 Notice?
A section 78 notice is the formal notice used when an insurer disputes liability for a claim or an aspect of a claim. It must state the decision and reasons and provide the information required by the legislation and applicable guidelines. Payment and work-capacity changes can also involve other statutory notices, so identify the document before choosing a response.
What should I do after receiving a dispute notice?
Save the full notice pack and attachments, note the date received, and gather the relevant medical, capacity, wage, or treatment records. Check the type of decision before choosing a review or dispute pathway.
How much does it cost to dispute a workers compensation decision?
IRO funding may cover approved legal professional fees and pre-approved disbursements for an eligible injured worker. Funding is not automatic: an IRO Approved Lawyer must assess the dispute and apply for an ILARS grant under the current criteria.
How long do I have to challenge a dispute decision?
There is no single time limit for every workers compensation decision. Check the notice, the legislation governing that decision, and any applicable Commission procedure. Preserve the notice and supporting records even if the next step is still being considered.
Keep these dispute guides open
- Practical insurer and evidence questions
- NSW workers compensation lawyers: statewide guide
- Current IRO and ILARS funding criteria
- Detailed workers compensation claim guide
- Claim denied guide
- Section 78 notice guide
- When an insurer disputes an accepted claim later
- Work capacity decisions guide
- Insurer ignoring psychological symptoms
- Weekly payments stopped guide
- PIAWE recalculation request guide
- Treatment denied guide
- Surgery denied guide
- Unfair IME report guide
- PIC disputes process guide
- Start a free claim check
What to do next
The available next step depends on the written decision, governing legislation, evidence, and any applicable review or Commission procedure. A claim check does not guarantee that a decision can be changed.