IME doctor says I need surgery – what now?

Sometimes during a WorkCover matter you’ll be required to see an independent medical examiner (IME).

And depending on the nature of your injury, they may recommend in their report that you have surgery.

Many people on WorkCover seem to be confused as to what impact this will have on their claim and what they need to do.

The rest of this page will explore the matter further.

If you saw the IME specifically in relation to a surgery request

If your specialist doctor has requested that the WorkCover insurer approve and fund surgery, and the insurer has organised an appointment for you to attend an IME and the IME agrees that you should have surgery – then the process to be followed thereafter is relatively simple.

The insurer should send you confirmation of surgery approval in writing.

You should then make contact with your specialist (assuming you still wish to have the surgery) and make arrangements to have the surgery.

One thing to keep in mind – the WorkCover insurer’s have set fees that they will pay for different surgeries.

So before you proceed with the surgery, it would be a good idea to contact your specialist and ask what their fees (and any associated fees such as the fees of the anaesthetist) will be.

If they intend to bill you over and above what the WorkCover insurer is prepared to pay, then you will be required to pay for the extra uncovered amounts. 

The rest of this page assumes that you have seen the IME doctor for a reason other than for an opinion in relation to whether a particular surgery request is reasonable.

The fact that the IME says that you need surgery will assist in the approval process

Given that the IME is a doctor that has been organised by the WorkCover insurance company, if you do want to have the surgery, then the doctor’s opinion is helpful.

You can read about WorkCover and the payment of surgery here.

When requesting that the insurer pay for surgery, there is an approval process that you’ll need to go through.

You’ll need to have your treating surgeon send a request for surgery to the WorkCover insurer.

The WorkCover insurer will then need to decide whether to agree to pay for the surgery, based on the medical material that they have – which includes the material from your treating surgeon.

If they require further medical material to make a decision, they may request comment from an independent medical examiner.

Given that they already have a comment from an independent medical examiner saying that you should have surgery, this will assist you if you do wish to proceed with the surgery.

Whether you have the surgery or not is your choice

If you think surgery is something that you you do want to explore, it would be a good idea to ask the WorkCover insurer to provide you with a copy of the independent medical examiners report.

If you have difficulty obtaining this report and you do not have a lawyer, then you should ask to speak to the team leader and make the request to them.

The team leader is the person that will be manager of the person that handles your claim with the insurer.

If you have a lawyer then it would be a good idea to ask them to obtain a copy of the IME report for you (they may already have a copy of it).

You should show a copy of the IME report to your GP who can then make a referral for you to see a specialist (if they deem it appropriate and if you haven’t previously seen one in relation to your injury).

If they don’t make a referral and you think that they should, you are able to obtain a second opinion from another doctor.

You should show a copy of the report of the IME to a specialist and get an opinion from them as to whether they recommend you have the suggested surgery.

You do not need to have the surgery

Just because an IME says that you should have surgery, does not mean that you need to have the surgery.

Whether you wish to have the surgery or not is up to you.

You can either discuss the IME’s opinion with your treating doctors – or not. It’s up to you.

But to reiterate, just because the IME doctor has said that you should have surgery does not mean that you need to have it.

You do not need to see a specialist and ask for their opinion in relation to whether you should have surgery if you don’t want to.

If you don’t have the surgery will that impact your claim?

No, it will not impact your claim if you have an IME who says that you should have surgery and you choose to not have the surgery.

It should have no impact on your entitlement to the payment of medical expenses by the WorkCover insurer.

And it should have no impact on your entitlement to be paid weekly payments.

It will have no impact on your entitlement to claim an impairment benefit lump sum or common law claim lump sum.

If you have an inexperienced claims manager, they could potentially make an issue of it saying, for example, that the current treatment that you are getting is not sufficient and pointing out that the IME has said that you should have surgery and therefore you should have it.

However, this would not be reasonable.

And you should rest assured that there is no obligation on you to have the surgery and your WorkCover claim should not be impacted if you elect to not undergo the surgery.

Conclusion

If a IME doctor that you see during the WorkCover process says that you should have surgery, you do not need to have the surgery.

If you elect not to undergo the surgery it should not impact your WorkCover claim.

If you do want to have the surgery, then you should ask the insurer for a copy of the IME’s report and provide this to your GP and/or specialist doctor and ask their opinion.

The fact that the IME has recommended that you undergo surgery should assist you to obtain approval for payment from the WorkCover Insurer.

If you saw the IME doctor specifically in relation to a surgery request made by your treating specialist, then if the IME doctor agrees that you should have surgery, then the next step would be to contact your specialist and make the appropriate arrangements to have the surgery, assuming you still wish to do so.