Do I have to attend an insurer-arranged IME, and what happens there?

Section 119 of the 1998 Act deals with medical examinations required by an employer for a worker who has given notice of an injury or is receiving weekly payments. The examiner is provided and paid for by the employer or insurer. The current SIRA Guidelines add practical limits to how referrals should be made.

An IME should address a real medical issue in the claim, such as diagnosis, whether work contributed to the injury, treatment causation or reasonable necessity, recovery, incapacity, physical capabilities, permanent impairment, or capacity for pre-injury or other duties. It should not be arranged merely to obtain another opinion when the available treating evidence already answers the question consistently and adequately.

An IME report is evidence. It is not, by itself, the insurer decision, a treatment plan, or a guaranteed permanent impairment result.

Before referring a worker, the insurer should identify the unanswered issue and consider whether the information can be obtained from the nominated treating doctor or another treating practitioner. Attempts to obtain the information should be documented. The examiner should have expertise relevant to the injury and the question being asked, and should not have a treating relationship or other conflict that undermines independence.

The location and format must also be reasonable. The appointment should comply with certified travel restrictions and account for disability, language, gender and cultural needs. A video examination is assessed case by case and is not a default substitute where a physical examination is required.

• Check whether the referral identifies the diagnosis, treatment, capacity, causation or impairment question.
• Check why the treating material is said to be inadequate, unavailable or inconsistent.
• Check the examiner specialty against the injury and the question.
• Tell the insurer promptly about access, interpreter, travel, medical or cultural requirements.

The worker must ordinarily receive written notice at least 10 working days before the examination. A shorter period is reserved for exceptional and unavoidable circumstances and must be agreed by all parties. More notice should be considered for rural and regional travel.

The notice should state the specific reason for the examination and why treating information was not enough. It should also identify the examiner and specialty, date, time, place, likely duration, what to bring, travel directions, support-person arrangements, any routine recording request, costs the insurer will meet, possible consequences of non-attendance, report and document access, objection steps and complaint contacts.

If recording is the examiner’s routine practice, the worker must be told and agree before the appointment is scheduled. If the worker does not consent and the examiner will not proceed without recording, the insurer is to arrange another examiner who will not record. A worker considering making their own recording should obtain consent and advice rather than assume it is permitted.

A worker may be accompanied by a person who is not their legal representative. That person cannot participate in the examination and may be asked to leave. The insurer must meet reasonable costs incurred by the worker, including wages, travel and accommodation; depending on the circumstances this may include prepayment or an escort.

• Take identification, the appointment letter and any records the letter specifically requests.
• Describe symptoms, treatment and function accurately without exaggerating or minimising them.
• Explain actual job tasks, hours and restrictions rather than relying only on a job title.
• Afterwards, make a factual note of the duration, tests, questions, support-person issue and any significant event.

A subsequent IME is not unrestricted. The Guidelines list situations such as a significant change or resolution of the injury, a material treatment change, a permanent impairment or work injury damages claim, new medical information supplied with a review request after a section 78 notice, an incomplete prior examination, at least six months since the last insurer-required IME, or significant documented reasons for a shorter interval.

The same examiner should ordinarily be used. A different examiner may be justified if the original examiner has stopped practising, the required specialty changed, the examiner is no longer in a convenient location, or both parties agree another practitioner is required.

Do not simply miss the appointment. Send the insurer a prompt written objection identifying the problem: insufficient notice, no stated medical question, treating evidence not considered, unsuitable specialty, excessive frequency, travel or accessibility restrictions, conflict, or another concrete reason. The insurer must consider the objection and respond, including IRO contact information.

The Guidelines state that benefits are not to be affected before adequate written notice is received. A decision to suspend weekly payments can only be made after an opportunity to comply with a reasonable request, on sound evidence, with written reasons and an explanation of what must be done for payments to be reinstated. Section 119 also addresses suspension of the right to recover compensation where a worker refuses or obstructs a required examination, which is why individual advice is important before refusing.

Ask for the IME report and the documents supplied to the examiner. The appointment notice should tell you that these can be requested and that the nominated treating doctor will receive the report. Legislation also provides report-access rights where a report is relevant to a decision disputing liability or reducing compensation.

Check the report against the accepted injury, actual duties, chronology, treating records, imaging and the medical question. Record factual mistakes separately from differences in clinical opinion. If a formal decision follows, respond to the legal and medical reasons in that decision rather than treating the IME report as the decision itself.