A threshold injury under the Motor Accident Injuries Act 2017 (NSW) includes a soft tissue injury and a psychological or psychiatric injury that is not a recognised psychiatric illness (adjustment disorder and acute stress disorder are the usual examples; s 1.6 and Motor Accident Guidelines Part 5).
If you're disputing an independent medical examination (IME) ordered by an insurer in a New South Wales Compulsory Third Party (CTP) motor accident claim, you have legal options to challenge the findings. This article explains how to dispute insurer-ordered IMEs under NSW law, including SIRA's role, practical steps, and time limits for Greater Sydney residents.
Legal Framework for Disputing IMEs
Under the Motor Accident Injuries Act 2017 (MAIA), insurers may request an IME to assess the extent of injuries and determine eligibility for benefits. However, claimants have the right to challenge the examination's findings if they believe the process was flawed or the report is inaccurate. SIRA (State Insurance Regulatory Authority) oversees the CTP scheme and provides guidelines on dispute resolution.
Key principles include:
- Medical independence: The IME must be conducted by a qualified medical practitioner with no conflict of interest.
- Reasonable grounds: You must have valid concerns about the examination's conduct or findings.
- Evidence requirements: Medical records, expert opinions, and documentation of the IME process are critical to support a challenge.
Steps to Challenge an Insurer-Ordered IME
- Review the IME report: Check for inconsistencies, incomplete assessments, or biased conclusions. Ensure the report addresses all injuries and follows SIRA's guidelines.
- Request an internal review: Contact the insurer's claims team to formally dispute the report. Provide specific reasons, such as:
- The examiner failed to account for pre-existing conditions.
- The report contradicts independent medical evidence.
- The examination was not conducted properly (e.g., incomplete tests).
- Lodge a complaint with SIRA: If the insurer refuses to review the report, you can submit a complaint to SIRA. They will assess whether the IME was conducted in accordance with the CTP scheme's rules.
- Seek independent medical evidence: Obtain a second opinion from a qualified specialist to challenge the IME findings. This evidence can be submitted to the insurer or SIRA.
SIRA's Role in Resolving IME Disputes
SIRA acts as the regulatory body for CTP claims and has the authority to intervene in disputes. They will:
- Investigate complaints about the IME process.
- Require insurers to provide justification for their findings.
- Make decisions on whether the IME was conducted fairly.
If SIRA finds the IME was flawed, they may order a new examination or adjust the benefits awarded. However, they cannot guarantee a change in the insurer's decision.
Practical Considerations for Greater Sydney Claimants
- Time limits: You must dispute the IME within 28 days of receiving the report, unless the insurer agrees to an extension. Delays may limit your ability to challenge the findings.
- Medical evidence: Keep detailed records of all treatments, specialist opinions, and correspondence with the insurer. This evidence is essential to support your case.
- Legal advice: Consider consulting a solicitor if the dispute escalates. They can help you navigate the process and ensure your rights under the MAIA are protected.
Example Scenario
Imagine a claimant who suffered a soft-tissue injury in a car accident. The insurer orders an IME, which concludes the injury is not serious enough for benefits. The claimant disputes this, citing ongoing pain and medical records showing a threshold injury. By challenging the IME and providing additional evidence, they may secure a more accurate assessment of their injury.
When to Seek Legal Advice
If the insurer refuses to review the IME report, or if you're unsure how to proceed, seek legal advice. A solicitor can help you:
- Navigate SIRA's complaint process.
- Challenge the insurer's refusal to reconsider the report.
- Explore options for independent medical assessments.
Next Steps
Disputing an insurer-ordered IME requires careful preparation and adherence to legal timelines. While you cannot guarantee a change in the insurer's decision, you have the right to challenge the process under NSW law. For personalized guidance, complete the quick, no obligation enquiry form to request contact about your circumstances.