Independent medical examinations

Published: 12 August 2019
Last edited: 17 April 2020

Independent medical examiner

An independent medical examiner is an appropriately qualified and experienced medical practitioner who can help to resolve an issue in injury or claims management.

When is an independent medical examination arranged?

An insurer may arrange an independent medical examination when information from the nominated treating doctor or treating specialist is inadequate, unavailable or inconsistent, and the insurer has not been able to resolve the issue directly with the treating doctor or specialist.

The insurer may arrange an independent medical examination to determine:

  • diagnosis of an injury reported by the worker
  • the contribution of work incidents, duties and/or practices to the injury
  • whether the need for treatment results from the worker’s injury and is reasonably necessary
  • recommendations and/or need for treatment
  • capacity for pre-injury duties and hours
  • the likelihood of and timeframe for recovery
  • capacity for other work/duties (descriptions of such duties are to be provided to the independent medical examiner)
  • what past and/or ongoing incapacity results from the injury
  • physical capabilities and any activities that must be avoided.

An insurer may also refer a worker for an independent medical examination in order to obtain an assessment degree of permanent impairment resulting from the injury (see 'Assessing permanent impairment').

An insurer may direct a worker to attend an independent medical examination, however they cannot require the worker to attend such an examination more frequently than outlined in the Workers compensation guidelines (the Guidelines). The Guidelines state that subsequent examinations can only be conducted in the following situations:

  • the employer/insurer has evidence that the worker’s injury has significantly changed or resolved, or
  • the employer/insurer has a request for, or evidence of, a material change or need for material change in the manner or type of treatment, or
  • the worker makes a claim for permanent impairment or work injury damages, or
  • the worker requests a review after receiving a notice (issued under section 78 of the Workplace Injury Management and Workers Compensation Act 1998 (1998 Act)) and includes additional medical information that the employer/insurer is asked to consider, or
  • the last independent medical examination was unable to be completed, or
  • it has been at least six months since the last independent medical examination required by the employer/insurer, or
  • the referrer can provide significant reasoning for the need for a referral in a shorter timeframe. This reasoning must be documented in the claim file and provided in the written advice to the worker regarding the referral.

There must still be a reason for referral and any subsequent assessment must be with the same examiner unless:

  • that examiner has ceased to practise (permanently or temporarily)
  • the specialty required to assess the injury has changed
  • they no longer practise in a location convenient to the worker, or
  • both parties agree that a different medical practitioner is required.

If a worker refuses to attend or obstructs the examination, the insurer may suspend the worker’s weekly payments until the examination has taken place.

Note: In special circumstances, such as during the COVID-19 (Coronavirus) pandemic, independent medical examinations may be conducted by video consultation, where appropriate.

Further information can be found in Insurer guidance: GN 6.8 Independent medical examinations.

Notification to the worker

The insurer is to provide the worker with at least 10 days written notice of the appointment. A shorter timeframe may apply if agreed to by all parties. The Guidelines require that the written notification to the worker is to include:

  • the specific reason for the examination
  • an explanation of why information from the treating medical practitioner(s) (or author of the assessment report to the insurer’s enquiry) was inadequate, inconsistent or unavailable
  • date, time and location of the appointment
  • name, specialty and qualifications of the independent medical examiner
  • contact details of the independent medical examiner’s offices and appropriate travel directions
  • the likely duration of the examination
  • what to take (for example, x-rays, reports of investigations/tests, comfortable clothing to enable an appropriate examination to be conducted)
  • information that the worker may be accompanied by a person other than their legal representative, however, the accompanying person must not participate in the examination and may be required to withdraw from the examination if requested
  • information for the worker when it is the independent medical examiner’s routine practice to record the examination on audio or video, that the worker can consent to or decline this before the examination is scheduled (the recording is only to proceed if the worker consents)
  • advice that the insurer will meet any reasonable costs incurred by the worker, including wages, travel and accommodation (this may include pre-payment of travel and accommodation expenses, and if the worker is not reasonably able to travel unescorted, expenses for the worker’s escort)
  • advice that a failure to attend the examination or an obstruction of the examination may lead to a suspension of:
  • advice that the worker can request a copy of the report, as well as documents that were provided to the independent medical examiner
  • advice that their nominated treating doctor will be provided with a copy of the examination report
  • advice that the workers compensation legislation gives the worker or a nominee a right to a copy of any report relevant to a decision made by a referrer to dispute liability for or reduce compensation benefits
  • what to do if the worker does not believe the examination is reasonable
  • what to do if the worker has a complaint about the conduct of the independent medical examiner
  • the SIRA fact sheet about independent medical examinations.

Unreasonable request

If the worker considers the requirement to attend an examination unreasonable, they are to advise the insurer of the reasons for their objection. The insurer must consider the objection, and advise the worker of their decision following this consideration.

Note: The Guidelines require insurers to consider whether the requirement to attend independent medical examinations are reasonable, having regard to changes to existing laws and public health orders in response to COVID-19 (Coronavirus).

Any decision to suspend payment of weekly compensation can only be made after the worker has had an opportunity to comply with a reasonable request. This decision must be made on the basis of sound evidence, and the worker advised in writing of the reasons for the suspension and what they must do in order for weekly payments to be reinstated.

Worker benefits are not to be affected before adequate written notice is received by the worker. This notice must detail other avenues the worker can pursue, including contacting the Workers Compensation Independent Review Office (WIRO) for assistance.

What the independent medical examination involves

The independent medical examiner will assess the worker to provide advice regarding the injury and/or treatment. The assessment will include talking to the worker about:

  • their medical and work history
  • what caused the injury or condition
  • how the injury affects them
  • treatment received and proposed
  • action taken in their recovery so far.

For physical injuries or conditions, the assessment may include a physical examination. For a psychological injury or condition, the independent medical examiner may conduct psychological testing.

The independent medical examiner will then write a report for the insurer, providing a response to the questions asked. They may also recommend further investigations or a follow-up assessment. The insurer is required to provide the worker with the report if they are relying upon it in a dispute or at the worker’s request.

Complaints about independent medical examinations

All independent medical examiners must abide by the Medical Board of Australia’s code of conduct, specifically section 8.7: ‘Medico-legal, insurance and other assessments’.

If the worker has concerns about the examiner’s conduct during the examination, they should raise those issues with the examiner at the time. The examiner should record the complaint and forward this to the referrer with their report. The worker should be advised to do the same.

Alternatively, the worker should raise their concerns with the referring party as soon as possible after the examination and the insurer should take action in accordance with its complaints management process.

If the issue is not satisfactorily resolved, the worker may forward their complaint to the Health Care Complaints Commission, the Medical Council of NSW or can contact SIRA on 13 10 50.