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Do I have to go to a medical appointment arranged by the insurer or superannuation fund?

 


Do I have to go to a medical appointment arranged by the insurer or superannuation fund?

Updated 6 May 2020

Whilst every superannuation fund and insurer approaches every claim in a different way, it is common that you will be asked to attend a medical appointment with a consultant doctor (or doctors) that the insurer or super fund chooses before a decision is made on whether to accept or reject your TPD or income protection claim.

The doctors the super fund or insurer chooses are usually specialist doctors and their qualifications vary depending on the nature of your illness and the issues in dispute in your case. The doctors may be neurologists, occupational doctors or psychiatrists (to name just a few).

What is an independent medical examination?

It is not unusual that you will be asked to attend appointments with more than one consultant doctor as part of the claim assessment. The super fund or insurer will often refer to these appointments as Independent Medical Examinations or IME’s and refer to the doctors as independent or IME doctors.

The independence of the doctors is not always certain. Often people are intimidated and concerned when they are asked to see consultant doctors and disappointed by the way they are treated by the doctors during the examination and then by the opinions which they set out in their reports.

For this reason, we are often asked, “do I need to attend the appointments?” The answer is not straight forward.

The starting point is that super funds and insurers are able to make reasonable enquiries relating to your health and your past, current and future work capacity.

Usually, it is reasonable that a super fund or insurer ask that you see a consultant doctor of their choice and sometimes the process can be useful for your claim. In some cases, we find that an assessment by a consultant doctor is useful as it can help to support your own treating doctor’s opinion about your work capacity or help clarify some issues that your treating doctors are unsure about. For example, these doctors can help provide or clarify a diagnosis.

This is because sometimes the consultant doctors which the super fund or insurer will send you to, are experts on the requirements of different jobs and the impact of different illness or injuries on your work capacity.

At other times the request that you see a consultant doctor can be unreasonable and the outcome of the appointment can appear to be predetermined. The doctor chosen by the super fund or insurer can be biased in the way that they assess the impact of your illness or injury on your work capacity.

Also, sometimes super funds and insurers will ask that you see a consultant doctor when there is more than enough medical material available to support your claim or you have already seen other consultant doctors (who support your claim).

Can I decline a request to see a consultant doctor?

Where there are good reasons to dispute the need to see a consultant doctor, you can object and argue that your attendance is not necessary.

Usually, you must provide reasons for your refusal and refusing can delay the assessment of your TPD or income protection claim. Sometimes, it may be necessary to put your objection in the form of a complaint and use the super fund or insurer’s internal dispute resolution process.

Can I get financial assistance to attend medical appointments requested by the insurer?

You can ask the super fund or insurer for assistance to meet the cost and inconvenience to you in attending a consultant medical appointment. This assistance may come in the form of travel vouchers, reimbursement for train or bus travel or accommodation assistance.

What if I’m not happy with the opinion of the insurer’s doctor?

If you’re unhappy about the opinion of a consultant doctor, it is important to remember that the opinions can be challenged and are just one opinion for consideration in the assessment of your claim.

We recommend you also read our article on “What to do if my TPD claim is rejected”.

Important information about medical appointments during the COVID-19 (Coronavirus) lockdown

Some super funds and insurers are still requesting that people attend medical assessments with consultant doctors during the COVID-19 lockdown.

Some of these assessments are going ahead by telephone or video link-up. This is most common for illnesses/injuries that don’t always need a physical examination (for example psychiatric assessments).

Other medical examinations are going ahead as normal. This is because when a medical examination goes ahead via telephone or video link, rather than in person, the quality of the conclusions reached may be reduced.

It is well publicised that if you have a chronic illness, the coronavirus can pose a very serious health risk for you. Therefore, we recommend that people who suffer from chronic illnesses (including, for example, heart and lung conditions or diabetes) or people who are otherwise concerned about attending appointments, speak to their treating doctors before attending.

If your doctors share your concerns, you should request that your doctor provide a certificate confirming their advice not to attend. You can then provide that certificate to your insurer and request that the medical examination is cancelled or postponed.

You might also request that the consultant doctor’s report be based on the available medical evidence without seeing you in person. Super funds and insurers sometimes call reports that do not involve a physical or telephone examination, a “desktop assessment”.

If the appointment is cancelled and the assessment of your claim goes ahead without the extra medical opinion, it’s possible that your claim will be rejected. This will depend on the other medical evidence which is available relating to your claim.

Also, postponement of the examination is likely to lead to a delay of your claim. Lastly, desktop assessments are not always as supportive of your claim as in-person assessments. This is because you don’t get to go and fully explain your situation.

Therefore, we recommend you seek advice about cancellation or postponement (or any other requests you make to your super fund or insurer) and the impact it will have on your TPD or income protection claim, before making any decisions.

Help?

If your super fund or insurer is not willing to assist you to attend an appointment which they have arranged for you, or you are unsure about whether or not you need to attend an appointment or would like to refuse to attend an appointment, do not hesitate to get in touch with today’s blog writer, superannuation and insurance lawyer Tom Cobban, for some free advice.

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