Motor accidents disputes - 1999 scheme

Disputes are assigned to the most appropriate dispute resolution pathway.

Medical dispute

Disputes are assigned to the most appropriate dispute resolution pathway.

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Lodgment
Lodgment Examination and assessment  Status of assessment  Review of a medical assessment  Further medical assessment 

Lodgment

Applications to resolve a dispute through the medical disputes pathway, and responses to medical dispute applications, may be lodged with the Commission. 

When to lodge a dispute resolution application 

A claimant may request a medical assessment if they disagree with the decision of the insurer on the following medical matters:

  • the degree of permanent impairment of the injured person caused by the motor accident
  • whether any treatment and care is reasonable and necessary in the circumstances or relates to the injury caused by the accident.

How to lodge an application 

Applications to resolve a medical dispute should be lodged via the Commission’s online portal. There is a single application process for all medical disputes. Claimants who are legally represented may have their lawyer lodge the application on their behalf.

If a self-represented claimant is unable to use the portal to lodge their application, they may contact the Commission to obtain a PDF copy of the form or have an application mailed to them. These applications may be lodged via email or post, or in person at the Commission.

All relevant information must be attached to the application. An application should not be lodged until all relevant material is available because it may not be possible to include further information later in the dispute resolution process.

How to respond to an application 

The respondent will receive a sealed copy of the application from the applicant and must respond within 20 working days from that date.

The response can be lodged by email through the Commission’s online lodgement portal.

If a self-represented respondent is unable to use the portal to lodge their response, they may contact the Commission to obtain a PDF copy of the form or have a copy mailed to them. These forms and the accompanying documents may be lodged via email or post, or in person at the Commission.

All relevant information that has not been included by the applicant should be attached by the respondent at the time the response is lodged. Respondents may not be able to submit further information at a later time.

How long does resolving a dispute take? 

The time taken to resolve a dispute depends on:

  • the issues in dispute
  • the standard of preparation by the parties
  • the willingness of parties to genuinely attempt resolution
  • whether a decision is appealed.

The Commission aims to resolve disputes as quickly as possible and will encourage the parties to resolve their dispute at the earliest opportunity.

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Examination and assessment 

Examination and assessment are conducted by the Commission’s medical assessors.

When and where will assessment take place? 

If a medical dispute is referred to a Medical Assessor, a Dispute Resolution Officer will arrange an appointment at the earliest possible time with a specialist who is accredited in the assessment of the injuries that are the subject of the dispute.

Medical assessments are conducted throughout NSW, at a location suitable to the claimant where possible. The assessment may be conducted by video when that is appropriate.

Claimants and legal representatives will be notified in writing by the Commission of the name of the approved medical specialist and the date, time and place of the assessment.

The insurer is required to meet the reasonable costs of the claimant attending this assessment.

What to expect at a medical assessment 

The appointed Medical Assessor will review the information provided by both parties, including the medical reports from the doctors who have examined the claimant at the request of their own lawyers or at the request of the insurer, and the medical reports from the doctors who have provided treatment. They will also review any other relevant documents, including the claimant’s statement and investigations such as X-rays, MRIs, ultrasounds and CT scans, to help to get a full picture of the claimant’s injury and its effects.

To understand more about the claimant’s injury, the Medical Assessor will ask about the circumstances that caused the injury, the effects of the injury, the treatment the claimant has had to date, and his or her medical history, including previous injuries.

The Medical Assessor will usually carry out an independent examination of the claimant at the assessor’s practice.

The Commission will arrange for an interpreter to attend the assessment and/or provide assistance for any disability needs, if the claimant requests this.

A claimant may have a support person attend with them at the assessment if the Medical Assessor agrees. However, the support person cannot take an active part in the assessment.

What to expect after a medical assessment 

The Medical Assessor will prepare a Medical Assessment Certificate that sets out their decision and reasons in relation to the medical dispute.

Medical Assessment Certificates are usually issued within 14 days  after the medical assessment.

If there are multiple physical medical assessments, a lead medical assessor is appointed and all non-lead Certificates are forwarded to the lead assessor who then issues a Combined Certificate.  The non-lead Certificates will be forwarded to the parties with the Combined Certificate.

About Medical Assessors 

Medical Assessors are highly experienced medical practitioners who have worked in a range of medical specialties. The role of the Medical Assessor is to examine the claimant and provide an independent assessment to the Commission.

Medical Assessors do not to give advice or recommend treatment for the claimant.

How the Medical Assessor is selected 

Medical Assessors are engaged directly by the Commission and are independent of claimants and insurers. The Commission will choose the next available Medical Assessor with the appropriate expertise to assess the claimant’s injury.

Medical Assessors may also sit on medical appeal panels.

Relevant resources 

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Status of assessment 

A Medical Assessor’s assessment about a claimant’s degree of permanent impairment, outlined in the medical assessment certificate, is final and binding on the parties.  If a party thinks that the medical assessment is incorrect in a material respect, they can lodge and application for a review by a medical review panel. An application for review must be lodged within 28 days of the Medical Assessment Certificate being issued. 

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Review of a medical assessment 

When to lodge an application for a panel review 

Either party to a medical dispute may make an application for a panel review of a medical assessment by a single Medical Assessor on the grounds that the medical assessment was incorrect in a material respect. Applications should be lodged within 30 days of the Medical Assessment Certificate being sent the parties by the Commission.

How to lodge an application 

Applications for a panel review should be lodged via the Commission’s online portal.

If a self-represented claimant is unable to use the portal to lodge their application, they may contact the Commission to obtain a PDF copy of the form or have an application mailed to them. These applications may be lodged via email or post, or in person at the Commission.

Applications for a panel review must include:

  • the decision of the single Medical Assessor that is the subject of the application for review
  • the reasons why the decision is considered to be incorrect in a material respect.

All relevant information must be attached to the application. An application should not be lodged until all relevant material is available because it may not be possible to include further information later in the dispute resolution process.

How to respond to an application 

The reply to an application for a panel review should be lodged via the Commission’s online portal.

A reply must be lodged within 20 working days of receiving the application for review.

If a self-represented respondent is unable to use the portal to lodge their reply, they may contact the Commission to obtain a PDF copy of the form or have an application mailed to them. These applications may be lodged via email or post, or in person at the Commission at the direction of the President.

The respondent should provide a reply to the application for further medical assessment as soon as practicable. The reply should include any response to the submissions made by the applicant and any documents the respondent wishes to have considered as part of the review of the medical assessment.

President’s determination

The President   will consider an application for review and the matter may only be referred to a medical review panel where the President is satisfied that there is reasonable cause to suspect that the medical assessment was incorrect in a material respect having regard to the particulars set out in the application.

The medical review panel 

If the review is allowed to proceed, it will be referred to a medical review panel, made up of a Commission Member and two Medical Assessors. The Medical Assessor who did the assessment being reviewed cannot be on the panel.

The members of the panel will meet, usually by telephone, to review the application and the information provided by the parties. The panel will also review the assessment and all the information previously available to the Medical Assessor who conducted the original assessment.

The panel may conduct a formal hearing if that is deemed necessary. One of the Medical Assessors on the panel may need to re-examine the claimant.

Once the panel has finished its review, it will issue a detailed decision which confirms the assessment and certificate of the original Medical Assessor or they will issue a new certificate to replace the original certificate.

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Further medical assessment 

When to lodge an application for further medical assessment 

Either party to a medical dispute may make an application for a further medical assessment on the grounds of deterioration of an injury or additional information about the injury. The application may be made at any time; however, the matter may only be referred once by either party for a further assessment.

How to lodge an application 

Applications for a further medical assessment should be lodged via the Commission’s online portal.

If a self-represented claimant is unable to use the portal to lodge their application, they may contact the Commission to obtain a PDF copy of the form or have an application mailed to them. These applications may be lodged via email or post, or in person at the Commission.

Applications for further medical assessments should include submissions as to the nature of the deterioration of the injury or the additional relevant information that is relied on. Any information supporting the application should be listed and attached at the time the application is made.

All relevant information must be attached to the application. An application should not be lodged until all relevant material is available because it may not be possible to include further information later in the dispute resolution process.

How to respond to an application 

A response to an application for further medical assessment should be lodged via the Commission’s online portal.

If a self-represented respondent is unable to use the portal to lodge their response, they may contact the Commission to obtain a PDF copy of the form or have an application mailed to them. These applications may be lodged via email or post, or in person at the Commission.

The respondent should provide a reply to the application for further medical assessment as soon as practicable. The reply should include any response to the submissions made by the applicant and any documents the respondent wishes to have considered as part of the further medical assessment.

The further medical assessment process 

The President will consider whether the deterioration or additional information referred to by the applicant is such as to be capable of having a material effect on the outcome of the previous assessment. If the President determines that the information or deterioration is such as to be capable of having a material effect on the outcome of the previous assessment,   the matter will be allocated for a further assessment with a Medical Assessor. The process for a further medical assessment is the same as that for an initial medical assessment. The Medical Assessor will consider all the information previously available to the Medical Assessor/s who conducted the original assessment/s and all certificates that have been issued by the Commission, including any that have been issued in the intervening period.

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