How SIRA Regulates Independent Medical Exams in NSW CTP Claims
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).
Insurer-conducted independent medical examinations (IMEs) are a key part of assessing injuries in NSW Compulsory Third Party (CTP) claims. Under the Motor Accident Injuries Act 2017, insurers may request IMEs to evaluate the severity of injuries and determine eligibility for benefits. The New South Wales Motor Accident Claims Authority (SIRA) oversees these processes and provides clear guidelines on how IMEs should be conducted.
SIRA’s rules state that IMEs must be performed by registered medical practitioners and must be relevant to the claimant’s injuries. The purpose of the exam is to assess whether the injury meets the threshold for compensation under the CTP scheme. However, claimants have the right to challenge IME findings if they believe the examination was inadequate or biased.
How Insurers Use IMEs to Assess Injury Severity
Insurers typically use IMEs to determine whether an injury qualifies as a 'threshold injury' under the Motor Accident Guidelines. This classification affects the type and amount of benefits a claimant may receive. For example, injuries meeting the threshold may entitle the claimant to weekly income payments or treatment and care benefits.
During an IME, the medical practitioner reviews the claimant’s medical records, conducts a physical examination, and provides an opinion on the injury’s severity. The insurer uses this assessment to decide whether to approve or deny specific benefits.
Options for Disputing IME Findings
If a claimant disagrees with the findings of an insurer’s IME, they have several options to challenge the decision. First, they can request a second opinion from an independent medical practitioner. SIRA also provides a formal dispute resolution process for claimants who believe the IME was conducted improperly.
Claimants should ensure that the IME is conducted in accordance with SIRA’s guidelines. This includes having the examination performed by a qualified medical professional and ensuring that all relevant medical information is reviewed. If the claimant feels the IME was not thorough, they may need to provide additional evidence to support their case.
Practical Steps for Claimants
When dealing with an IME, claimants should take the following steps:
- Prepare medical records: Ensure all relevant medical documents are available to support the claim.
- Understand the purpose of the IME: Know that the examination is used to assess injury severity, not to determine fault.
- Seek clarification: If unsure about the process, ask the insurer or SIRA for details.
- Challenge the findings: If the IME is not conducted properly, request a second opinion or use the dispute resolution process.
Time Limits and When to Seek Advice
There are time limits for disputing IME findings, so claimants should act promptly. If the IME results in a decision that affects the claimant’s benefits, they should seek legal advice to understand their options. SIRA also provides resources to help claimants navigate the claims process.
Next Steps
CTP claims involving IMEs can be complex, and the outcome often depends on the specific circumstances of the case. To request contact about your circumstances, complete the quick, no obligation enquiry form.