Many workcover victims ask us whether IMEs can prevent an injured worker (you) from getting recommended surgery. Unfortunately the answer is “yes” but the following tips may ensure you win the “battle of the medical opinions” and have your surgery approved by workcover.
Unless life-saving surgery, injured workers are often sent to an independent medical examination before their recommended surgery is approved by workcover.
You all know by now that an IME is a medical examination, undertaken by a doctor that the insurance company
sends you to, at their cost, to get an ‘independent’ medical opinion about the cause and/or treatment for your injury.
Unfortunately there is still often a “disagreement” about the recommended course of an injured worker’s treatment.
Tips to ensure your surgery is accepted by workcover
If your treating specialist recommends surgery, and you want to go through with the procedure, you basically hope for the best that the IME doctor will agree, but you should prepare for the possibility that the IME will not agree.
A few tips to help you win the battle of the “experts” and have your surgery covered
- First of all it is very important that you have a treating specialist who is very qualified in the field of your injury and who has a good reputation. If you suffer from a shoulder injury, ensure you are being treated by an orthopedic surgeon who specialises in ‘upper limb’ surgery (generally shoulder, elbow, wrist). The recommendation given by an ‘expert in the field’ will undoubtedly carry more weight than an opinion of for example a ‘general orthopedic surgeon’.
- This is important in the event your workcover insurance company sends you to an IME who specialises in the particular area your injury. So if your treating doctor does not have much experience in this type of procedure, or is a general surgeon rather than a specialist, then the recommendation may be given less weight.
- Credibility is also very important. The reputations of the doctors can sway the opinion one way or the other.
Honestly, a lot of workcover insurance companies screw this part up by sending injured workers to “hired guns” that are known to say whatever needs to be said, not necessarily the truth.
- If your doctor/surgeon has the experience and expertise to give the opinion for surgery, be sure that s/he backs it up.There needs to be a rationale/explanation behind the decision for surgery, other than to say that, for example, if physio does not work then this surgical procedure should be tried. Your surgeon needs to give specific medical reasons why s/he thinks that this is the right procedure. This is so that a biased IME’s opinion that surgery is not necessary or ‘reasonable’ can be dismissed easier.
When you want to get your surgery covered, it can be a frustrating process to have to fight to have your opinion accepted. But with the right medical evidence and support (and with a good lawyer in your corner) you have a much greater chance at winning the “battle of the medical experts”.
Also remember that you can challenge any decision the insurer makes, by lodging a conciliation (VIC). Again, in order to ‘win’ your conciliation, it will be important to seek as many medical reports as possible in your favour (i.e. detailing why you would benefit from surgery). The more ‘credible’ your treating doctors are (and their reports) the easier it will be for you to prove the conciliator (or a medical panel) that you really need that recommended surgery.
You don’t need workcover’s approval to seek medical reports for a conciliation in VIC – simply ask your treating doctors (can be anyone (or all) who treats you from your physio to your pain specialist, psychiatrist and specialist surgeon) to write a report for the purpose of conciliation and ask them to bill your insurance company directly.