The 6-Month WorkCover Review: What Insurers Look For

The typical triggers for a week 26 review

Three factors most often trigger an audit. First, slow clinical progress — if the Certificates of Capacity have not changed in three or four months, the insurer will ask why. Second, inconsistency between reports — a physio progress note that does not match the doctor's certificate, or a rehab provider workplace assessment that contradicts reported restrictions. Third, approaching spend thresholds — when cumulative treatment costs or total weekly-payment days cross internal triggers, a review is automatic.

For psychological injury claims, a fourth trigger applies — the extended median time off work for mental-health claims (35.7 weeks versus 7.2 weeks for all-injury) means the review window often coincides with heavier medical and vocational assessment. We keep your doctor and psychologist in step through these reviews.

What the IME appointment actually looks like

You receive a letter from the insurer naming the independent medical examiner, the date and time of the appointment, and the questions the IME has been asked to address. The appointment itself usually runs 45 to 90 minutes. The IME doctor takes a detailed history, conducts a physical or psychiatric examination, and reviews your medical file.

They do not treat you. They do not change your Certificate of Capacity. Their role is to write a report back to the insurer answering the specific clinical questions asked — usually diagnosis, prognosis, work capacity, and whether the injury is work-related and has reached maximum medical improvement.

You are entitled to take a support person with you. You should go in well rested, with a written summary of your symptoms and a list of the medications and treatments you are currently receiving. We walk you through what to expect beforehand so you are not walking in cold.

After the IME — how decisions are made

The IME report usually lands with the insurer within two to four weeks. The insurer then decides whether to maintain, adjust, or dispute the current status of your claim. Any adverse change — reduction in weekly payments, termination of a treatment modality, or a change to work-capacity status — must be issued as a written work-capacity decision with reasons, under the SIRA guidelines.

You can ask the insurer for an internal review within the time set out on the letter. The Independent Review Office (IRO) gives free, independent help, and if the review doesn't resolve it, the Personal Injury Commission decides the dispute. If you need legal advice, we put you in touch with a compensation lawyer. Most WorkCover disputes qualify for IRO funding, which usually means the legal costs aren't yours.