What can I do if the insurer delays deciding my claim?

The legislation creates duties and consequences for particular failures, but an expired period should not be described as automatic acceptance of every claimed injury or expense. The result depends on the benefit, whether a valid notification or claim was made, provisional acceptance, missing information and the remedy sought.

A case manager saying that a matter is “under review” does not identify the legal position. Ask whether liability is provisionally accepted, fully accepted, disputed, subject to a reasonable excuse or awaiting specified information, and request the answer in writing.

For claims governed by Part 3 of the 2026 Guidelines, an insurer receiving an incomplete claim must give written notice within three business days specifying the additional information needed. Some primary psychological and relevant-injury claims have separate regulation requirements.

Respond item by item. If a request is unclear or disproportionate, ask how the information relates to the decision. Keep proof of supply. Do not assume a request for records gives the insurer unlimited permission to delay or collect unrelated material.

• Date the injury was reported to the employer and proof of that report.
• Date the insurer first received notification and the claim reference.
• Date each claim, Certificate of Capacity, treatment request, quote or report was supplied.
• Every insurer request for missing information and the date it was answered.
• Any provisional acceptance, reasonable-excuse or incomplete-claim notice.
• Dates of follow-up calls, written escalation and any proposed decision date.

IRO accepts complaints about insurer conduct affecting workers compensation rights and obligations, including delays in determining claims. It can contact the insurer and assist with complaint resolution. Its published delay reports confirm that delayed liability decisions are a recurring claims-management problem.

A complaint does not itself determine disputed liability or substitute for a PIC application. Give IRO the claim number, insurer, decision sought, lodgement proof, missed period, follow-up history and the practical effect of the delay.

The correct PIC application depends on the benefit and whether there is a formal dispute or a failure to determine. For example, the PIC Rules provide an interim-payment-direction process for specified failures, including some failures to determine medical-expense claims. Other matters may require a liability dispute application or medical pathway.

Do not lodge a generic application simply because 21 days have passed. The application should identify the statutory entitlement, respondent, orders sought and evidence. ILARS funding may be available for eligible legal assistance, but an IRO Approved Lawyer must assess the matter and IRO must approve any grant.

SIRA's current guidance distinguishes ordinary physical claims, primary psychological injuries and relevant injuries caused by bullying, sexual harassment, racial harassment or excessive work demands. Relevant-injury claims can involve a 42-day determination period, interim entitlement payments, mandatory internal review and a possible Industrial Relations Commission question about relevant conduct.

Do not apply the seven-day provisional-liability table mechanically to a relevant-injury claim. The notification date, injury classification and alleged event must be checked. Secondary psychological symptoms arising from a physical injury are not the same claim category. This guide excludes exempt and specialist worker schemes.

A worker sends a specialist treatment request, quote and clinical rationale to the insurer and receives no decision. The worker keeps the original email receipt, asks whether anything is missing, receives no identified deficiency and prepares a chronology showing the 21-day period relied on. The worker may then consider an IRO complaint and obtain advice about the appropriate PIC remedy. This example illustrates process only; it does not establish that the treatment is payable.