Claim assessment criteria

To assess your claim, your claims manager will look at the information you provided, as well as information from your employer, your doctor and any other medical professionals treating you. Using this information, they will decide whether your claim meets all the criteria:

• You are covered by the Comcare scheme.
• You reported your injury or illness as soon as you could.
• You provided all necessary documents.
• You have an injury or illness.
• The injury or illness led to impairment, incapacity or death.
• The injury or illness is connected to work.
• No exclusions apply.

These criteria come from the Safety, Rehabilitation and Compensation Act 1988 (SRC Act), which sets out the rules for the Comcare scheme.

You are covered by the Comcare scheme

Your claims manager will check that you are covered by the Comcare scheme, which provides workers’ compensation for employees of:

• Australian Government departments, agencies and authorities
• companies that self-insure through Comcare (known as self-insured licensees).

See: SRC Act, section 5.

You reported your injury or illness as soon as you could

Once you’re aware of your injury or illness, you must tell your employer about it as soon as you can, taking into account your personal circumstances. 

If you took longer to report your injury or illness, your claim may still be accepted if:

• there is a good reason for the delay (such as being overseas, not knowing you had the right to claim compensation, or making a genuine mistake)
• the delay doesn’t affect the claims manager’s ability to assess your claim.

See: SRC Act, section 53.

You provided all necessary documents

To make a claim for compensation, you must submit:

• a completed claim on the correct form – if you’re not sure which form to use, ask your employer
• a medical certificate from your doctor or specialist. 

See: SRC Act, section 54.

You have an injury or illness

If your claim meets the basic requirements above, your claims manager will then classify your condition as one of these:

• an injury, which usually happens suddenly and causes a clear physical change (such as a broken bone)
• an illness (called a ‘disease’ in the SRC Act), which usually develops over time (such as a stress-related illness or repetitive strain)
• aggravation, which is where an injury or illness you already had was made worse.

See: SRC Act, sections 5A and 5B.

The injury or illness led to impairment, incapacity or death

Next, your claims manager will look at how the injury or illness affected you. Compensation can only be paid if the injury or illness led to one or more of:

• part or total loss of your earnings (known as ‘incapacity’)
• damage to part of your body, or loss of function in part of your body (known as ‘impairment’)
• a loss of financial support for dependants because the worker died.

See: SRC Act, section 14.

The injury or illness is connected to work

Next, your claims manager will look at the relationship between your work and the injury or disease. To be eligible for compensation, your injury or illness must be sufficiently connected to your work. The way your claims manager assesses this connection depends on whether you have an injury or an illness. 

If you have an injury

To be eligible for compensation, your injury must have happened either:

• while you were working or in connection with undertaking your work duties (such as a warehouse worker injuring their back as a result of lifting heavy boxes)
• while you were taking part in an activity connected with your work or doing something incidental to your duties (such as a work-mandated training session)
• because of violence that wouldn’t have happened if you had not been at work or doing your job
• while you were at your workplace for work purposes (such as slipping in the office kitchen)
• while you were temporarily away from your workplace on a regular break (for example, visiting a café on your lunch break)
• while you were temporarily away from your workplace doing a job-related task or following instructions from your employer (for example, attending a meeting, training or a conference)
• while travelling for work as instructed or approved by your employer (for example, to attend education or training, or a medical or rehabilitation appointment)
• while working overseas in Afghanistan, Iraq or Ukraine or as part of the Australian Civilian Corps
• while receiving approved treatment for a medical condition already accepted under the Comcare scheme (for example, where a problem in surgery causes further injury).

If you were injured travelling between home and your usual workplace, this is not covered.

See: SRC Act, section 6.

If you have an illness

To receive compensation, there must be a significant link between your work and the illness (called a ‘disease’ in the SRC Act).

Your claims manager will consider:

• how long you have been employed
• the type of work you do, including specific tasks
• whether any activities you do outside of work could have contributed
• any predisposition you had to the illness
• anything else that affected your health. 

Some illnesses are known to be linked to certain types of work. Therefore, your claims manager will automatically consider certain illnesses to be work-related, unless it’s proven otherwise. These include:

• post-traumatic stress disorder for first responders
• certain cancers for firefighters
• illnesses connected to things that people are exposed to at work, such as asbestos or silica (known as ‘deemed diseases’).

For some illnesses, you must have been working in a particular role for a certain length of time for the assumption to apply.

See: SRC Act, section 7.

If you have a psychological injury or illness

If your injury or illness is psychological, your claims manager will:

• review your medical information and the details of your case
• look at what happened at work to see if there is a significant connection between those events and your injury or illness
• use medical information to decide whether your reaction to those work events goes beyond what is considered a normal psychological response.

General stress or frustration from work is unlikely to meet the criteria. To be recognised, your psychological injury or illness must:

• have a mental or emotional impact beyond the typical response to workplace situations
• be supported by medical information
• show a strong connection to your work.

No exclusions apply

In some specific situations, the Comcare scheme will not pay compensation. Your claims manager will check whether any of these situations apply to your claim.

You will not be eligible for compensation if:

• your injury or disease was caused by reasonable administrative action (such as a reasonable performance appraisal, disciplinary action or suspension) 
• you lied about not having previously had the same or a similar illness to the one you are now making a claim for
• you intentionally injured yourself, or knowingly and unreasonably exposed yourself to a high risk of injury
• your injury or disease was caused by your own deliberate and serious misconduct, for example, because you were under the influence of alcohol or non-prescribed drugs (however, if there was a serious injury or death, compensation may still be payable). 

See: 

• SRC Act, section 4
• SRC Act, section 5A
• SRC Act, section 7
• SRC Act, section 14.

More information

• Comcare’s Guidance on applying the SRC Act (‘Initial determination’ section) provides detailed advice for claims managers on how to apply the assessment criteria.