What is a WorkCover independent medical examination?

An independent medical examination is an appointment with a specialist medical practitioner, organised by the insurer, to address some aspect(s) of your worker’s compensation claim or litigation. Independent medical examiners that are commonly engaged in WorkCover claims include:

• orthopaedic surgeons;
• occupational physicians;
• allied health practitioners (osteo, chiro, physio);
• pain specialists; and/or

Depending on the nature and circumstances of your workplace injury, there are other independent medical examiners that may be required.

An independent medical examination is often required by the WorkCover insurer in the following scenarios (this is not an exhaustive list):

• Where the insurer is determining liability in a claim;
• Where the insurer is determining whether to pay for medical treatment or not;
• Where the insurer is considering return to work activities and objectives;
• Where the insurer is considering eligibility for ongoing entitlements.

The WorkCover insurer will often arrange an independent medical examination at certain milestones of a claim:

• After lodgement of the claim (initial assessment)
• After 52 weeks of payments (first entitlement period)
• After 130 weeks of payments (second entitlement period)

Medical examinations for initial assessment of your WorkCover claim

For the initial assessment after lodging your WorkCover claim, the independent medical examination is required to determine liability for a claim.

The insurer will want to know what your injuries are, what caused your injuries, whether your employment was the significant contributing factor to your injuries and whether you have any capacity to return to your pre-injury job. This will assist the insurer in forming its determination on whether to accept or reject your claim.

Medical examinations for first entitlement period

For the first entitlement period, the independent medical examination is required to determine how you are progressing with your treatment and whether you have any capacity to return to your pre-injury job.

If you do have capacity, according to the independent medical examiner, the insurer will likely terminate your weekly payments. If you do not have capacity, according to the independent medical examiner, the insurer is not likely to terminate your weekly payments.

Medical examinations for second entitlement period

For the second entitlement period, the independent medical examination is required to determine whether you have any capacity to return to suitable employment.

Similar to the first entitlement period, if you do have capacity, the insurer will likely terminate your weekly payments and must provide you 13 weeks’ notice of this, in writing. If you do not have capacity, the insurer is not likely to terminate your weekly payments.

If the insurer makes an unfavourable decision, you have a right to challenge the decision through conciliation at the Workplace Injury Commission.

Other than these common milestones, where an insurer receives a request for medical treatment, such as surgery, the insurer can engage an independent medical examiner to provide their opinion on the requested treatment. The opinion of the independent medical examiner can influence the insurer’s decision. If the independent medical examiner’s opinion is unclear or indeterminate, a clinical panel review may be requested by the insurer. This can take months.

Yes, you can.

You can request a copy of the report from your WorkCover case manager directly or through the Freedom of Information process. The Freedom of Information process can take up to 28 days to be completed and there may be a fee payable for access to the documents.

If you receive a copy of the report, it is always recommended that you read the report in the company of a trusted person or your treating doctor as this can help you understand the terminology and opinion reached by the examiner.

It can take between 4 to 6 weeks to provide an independent medical examination report. Some examiners are quicker than others and the timeframe for obtaining these reports rests heavily on administrative processing.

An independent medical examiner is engaged to provide an opinion about your medical condition. They observe your actions and words and report back to the WorkCover insurer about you. It is therefore not surprising that an examination can be scary.

Providing a consistent and accurate account of your injury and medical history to all doctors is vital for the success of your Workcover claim.

Here are some tips on how to best prepare for an independent medical examination:

• Refresh your memory regarding how and when your injury occurred;
• Refresh your memory with your medical history – they may ask you about any past medical history;
• Have a list of your doctors and treatments that you have had to date – medical terms can be very confusing to remember but have a basic understanding of what treatments you have had and be able to explain them if asked;
• Explain your current symptoms – be able to describe what you experience on a day-to-day basis, regardless of how minor that symptom may be;
• Bring a support person with you – they will have a passive role to play during the examination, but it can be helpful to have someone you trust with you to take notes;
• Have the right expectations – the independent medical examiner is not there to treat your injury, only to provide an opinion. It is important to be genuine, honest and clear when answering their questions and to cooperate in the examination to the best of your ability;
• Punctuality – always attend the examinations early. If you are late or miss the examination, it can be several months before you have another medical examination which in turn will cause delays in your claim.

The independent medical examiner will be provided with copies of your medical files and any other documents that the WorkCover insurer deems is appropriate for the assessment.

You do not have to bring documents with you to the examination but it is always recommended that you do. Documents to bring with you can be:

• your claim form;
• any original/copy radiology (MRI, CT scan, x-ray);
• any reports/letters you have from your own treating doctors.

You can report the behaviour/conduct of the independent medical examiner to your WorkCover case manager by email or phone. Be respectful and courteous in your dealings with the case manager.

The case manager will acknowledge your report and advise if an alternative independent medical examiner is required in the circumstances. You can also complain about the behaviour/conduct of the examiner to the Victorian WorkCover Authority.

There are specific examiners that the Victorian WorkCover Authority approves and where there have been many complaints about a particular examiner, the Victorian WorkCover Authority may re-consider whether to engage them for future examinations or not.

There is no course of action for compensation against an insurer for the behaviour/conduct of an independent medical examiner, nor against the independent medical examiner themselves.

If the behaviour/conduct of the examiner is grossly negligent and falls below the reasonable standard of care of a medical practitioner, and you suffer injury/loss/damage as a result of this alone, you may be entitled to make a medical negligence claim.

If the WorkCover insurer makes an unfavourable decision based on the opinion of the independent medical examiner, you can challenge the decision through conciliation at the Workplace Injury Commission.

If the insurer does not make an unfavourable decision and there are no changes to your entitlements, there is no specific avenue for you to dispute the independent medical examiner’s opinion. You can choose to provide a copy of the report to your treating medical practitioner if you wish to discuss it with them.

Yes, you technically can. However, you should not expect that they will provide you with medical advice.

A WorkCover independent medical examiner can refuse to provide you with advice because they are not there to treat your injuries. Their role is to provide a medical legal opinion about your injuries and to answer specific questions requested of them by the WorkCover insurer.

If you have an upcoming independent medical examination, we encourage you to discuss it with your treating doctors. They can direct and guide you on how best to approach these examinations because they too are medical practitioners.

If you have any further concerns about the examination or, as a result of the report your WorkCover claim is denied or your payments or medical expenses are terminated, you have options and rights. Polaris Lawyers are highly experienced worker’s compensation lawyers. We provide free initial advice. Remember, it costs you nothing to find out where you stand.