Can an independent medical examiner prevent me from getting surgery?

surgery-workcover

I have recently received several questions from workcover victims about independent medical examinations – in particular whether IMEs can prevent an injured worker (you) from getting the recommended surgery.

Well, unfortunately the answer is YES.

If you have been injured on the job or are involved in a personal injury case, the workcover insurer will often ask you to undergo an independent medical examination (IME). These examinations are -of course- with a medical examiner of the insurer’s choice. They are often notorious for minimising the extent of your injury, thereby limiting the insurer’s liability!

In theory an independent medical examiner can prevent you from getting surgery or any other treatment, test, benefit

Tips on how to protect yourself during independent medical examinations

You can read about tips on how to prepare and protect yourself for and during an IME here

You are always entitled to appeal a workcover decision (based on an IME) at Conciliation in the first instance

  • Make sure you get a formal, written letter from your workcover insurance – aka a REJECTION LETTER – detailing the reasons why your surgery (or any other treatment or test) has been denied
  • It is very useful to send a certified letter (with receipt) to the workcover insurer and to ask for the curriculum vitae and specialty of the examiner and also ask the insurer to explain why it chose this particular examiner. Also ask the insurer to send a copy of the examination report to your primary physician and/or specialist – I assure you, they will cringe.
  •  Challenge the insurer and ask them why they did not send you to an examiner with more expertise, experience and training for your injury and who treats patients who have similar injuries in the first instance. For example, you will often see that the workcover insurance will send you to a “general surgeon” (who deals with guts, gallbladders and small stuff like warts!) to assess a highly complex orthopedic problem. A general surgeon is not an orthopedic. A general surgeon is not a neurologist. A general surgeon or a general orthopedic surgeon is not a specialist shoulder/hip/spine surgeon, see what I mean?

So you have a real good chance to have the decision (i.e. not to allowed to have surgery) successfully overturned by the ACCS. All you need is:

  • the rejection letter from the workcover insurance company and their reasons for denying you surgery
  • the CV and qualification details from that IME (who most often will not be qualified in the field of your injury and hence will not have a leg to stand on)
  • supportive letters (to support the need for surgery) from your treating GP and most of all, from your treating specialist surgeon, explaining the reasons why the surgery is needed
  • a second, reputable specialist surgeon’s opinion (in your favour) may be helpful and remember that you are entitled to a second opinion under workcover (which they have to pay for)
Don’t let workcover get away with denying you what you are legally entitled to!
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Guest

Thank you for a very informative post!

workcovervictim
Guest

Glad it’s useful- and good luck with ACCS (if that’s where you’re heading) – you’ll see most cases do get overturned at Conciliation…I’ll cross my fingers and toes for you 😉