When you are injured at work in NSW, understanding your entitlements begins with one fundamental question: how are workers compensation injuries assessed? A workers compensation injury assessment involves a sequence of steps — starting with an examination by your treating doctor, followed by insurer review, and in some cases, a formal workers' compensation medical assessment or dispute resolution process. The outcome determines your eligibility for weekly compensation, medical expense reimbursement, and in more serious cases, a lump sum payment based on the degree of whole person impairment resulting from your injury.
Since 1926, all workers in New South Wales have enjoyed the benefit of statutory protection for the purpose of providing, if the worker is injured and unable to work and/or requires medical treatment, benefits to ensure that they are adequately compensated.
Successive NSW Governments have reduced the benefits available to injured workers through a series of reforms, resulting in what is today one of the most restrictive Workers Compensation Schemes ever enacted. Despite these limitations, the Scheme continues to provide benefits for all injuries suffered by a worker, whether physical or psychological.
Any injury that affects a worker’s ability to perform their usual occupation or results in some degree of whole person impairment or requires medical treatment is capable of being assessed under the Scheme.
The initial stage of any workers compensation injury assessment begins with your treating doctor. Your doctor will examine your injury, establish the causal connection between the injury and your employment, and provide a formal report or Certificate of Capacity. This document records the nature and severity of your injury, your capacity (or incapacity) for work, and the medical treatment required. It forms the foundation of your claim.
A workers compensation medical assessment can be conducted by different parties at different stages of your claim. Understanding how each assessment functions is important to protecting your rights.
Treating doctor assessment: Your own doctor is the first to formally assess your injury. They will prepare a Certificate of Capacity and medical report detailing the diagnosis, the causal link to your employment, your degree of incapacity for work, and the treatment recommended.
Independent medico-legal assessment: If the insurer disputes your claim or requires additional information, they may arrange an independent medical examination conducted by a doctor of their choosing. This assessment evaluates the same criteria, including severity, work capacity and treatment needs, but is commissioned by the insurer rather than by you or your treating practitioner.
Approved Medical Specialist (AMS): In the event of a formal dispute before the Workers Compensation Commission, an Approved Medical Specialist may be appointed to independently assess the injury and determine the impairment assessment for workers compensation purposes. The AMS determination is binding on all parties, with very limited grounds available for appeal.
The injury is initially assessed by your treating doctor, who provides a certificate and/or report detailing the nature of the injury, the causal link between the injury and the employment, the extent of any incapacity for work, and any treatment required. The insurer must then determine whether to accept or reject the initial assessment.
In the event that the assessment is accepted, the worker will receive benefits under the Workers Compensation Scheme including payment of weekly compensation (wages) for periods of absence from work and payment of all reasonable and necessary medical treatment expenses.
If the insurer rejects the initial assessment, they will arrange their own independent medico-legal examination of the injured worker. If the medico-legal assessor agrees with the initial assessment provided by the treating doctor, then the benefits referred to will be paid by the insurer voluntarily.
If the independent assessor does not agree and a dispute arises, the matter will need to be determined through the Workers Compensation Commission. An application can be made to resolve the dispute, which will result in the appointment of an Approved Medical Specialist who will determine the issue. That determination is binding upon the parties, with very limited grounds of appeal available.
One of the most significant outcomes of a workers compensation injury assessment is the determination of permanent impairment. Where an injury results in lasting physical or psychological consequences, the degree of impairment is measured through a formal impairment assessment for workers compensation purposes.
Impairment is expressed as a percentage of whole person impairment (WPI) — a standardised measure used to quantify how much the injury has reduced your overall functional capacity. A specialist assessor evaluates your injury against the guidelines established under NSW workers' compensation legislation to determine your WPI percentage.
Currently, a lump sum compensation payment is available where the degree of whole person impairment meets or exceeds the required threshold — greater than 10% whole person impairment for most physical injuries. Separate thresholds apply to psychological injuries.
The outcome of a whole person impairment assessment for workers compensation purposes directly determines whether you are eligible for a lump sum payment, and if so, the amount of that payment. Engaging a specialist workers compensation lawyer at this stage is strongly recommended to ensure the assessment is conducted fairly and that your entitlements are properly protected.
The outcome of your workers compensation injury assessment has direct implications for the benefits and compensation you may receive. There are three principal categories of entitlement:
Weekly compensation payments: If your injury results in a partial or total incapacity for work, you may be entitled to weekly payments equivalent to a percentage of your pre-injury average weekly earnings. The amount varies depending on the extent of your incapacity and the duration of your claim.
Medical and treatment expenses: Reasonable and necessary medical treatment expenses are payable by the insurer, including hospital fees, specialist consultations, physiotherapy and rehabilitation costs.
Lump sum compensation: Where your injury results in permanent impairment assessed at greater than 10% whole person impairment, you may be entitled to a lump sum payment. The amount is calculated based on the assessed WPI percentage and the applicable compensation table under NSW legislation.
Workers compensation injury assessments do not always proceed without complication. Several common issues can arise that significantly affect the outcome of a claim:
Insurer disputes: Insurers may dispute the causal link between your injury and your employment, the severity of your injury, your capacity for work, or the treatment recommended by your doctor. These disputes can delay or reduce your entitlements.
Incorrect or inadequate assessments: An independent medical examiner appointed by the insurer may not accurately reflect the true extent of your injury. Incorrect whole person impairment assessments can result in significantly reduced or denied lump sum payments.
Delayed approvals: Administrative delays in processing claims, approving treatment or scheduling assessments can leave injured workers without income or medical support for extended periods.
If you encounter any of these issues, seeking legal advice promptly is essential.
If you have been injured at work, you should consider speaking to a workers compensation lawyer as early as possible — even before your claim has been formally assessed. Legal advice is particularly important if:
Your claim has been rejected or disputed by the insurer
You have received a settlement offer you are unsure about
Your injury may result in permanent impairment and you want to ensure the assessment is conducted properly
Your weekly payments have been reduced or have ceased
You are approaching a time limit for making a claim
Time limits apply to some workers compensation claims in NSW. Delays in seeking advice can affect your entitlements. Early legal involvement can make a significant difference to the outcome of your claim.
Brydens Lawyers are the experts in the prosecution of all workers' compensation claims. For expert legal advice and representation, contact Brydens Lawyers without delay — time limits may apply to some workers compensation claims.
For a free*, no-obligation consultation, call Brydens Lawyers on 1800 848 848 or book online today. Our No Win, No Fee* policy means you can access expert legal representation without financial risk. *Conditions apply.
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