Insurer-arranged medical examinations are a standard part of the TPD claims process across all nine retail insurers on IMFL's panel. The examination tests three questions the insurer needs answered before applying the policy definition:
- Is the condition correctly diagnosed?
- Is it permanent (after all reasonable treatment and rehabilitation)?
- Is it likely to prevent the relevant occupation?
The legal label is usually 'Independent Medical Examination' or IME. The Australian Securities and Investments Commission has noted that the practice has historically attracted concerns about the meaning of 'independent' when the examiner is paid by, and frequently retained by, the insurer.
The contractual right to request an examination
Every panel PDS reserves the insurer's right to require the claimant to undergo medical, occupational, or functional examinations. The wording sits in the Claims section of each PDS.
- AIA Priority Protection (PDS 9 November 2025, Section 12.1, page 221): the assessor must be satisfied 'after reasonable consideration of all relevant medical and other evidence', which includes examinations the insurer arranges.
- TAL Accelerated Protection (PDS 12 December 2024, Section 9, page 88, and Section 3 Claims): the insurer's opinion is formed 'after consideration of medical and any other evidence'.
- OnePath OneCare (PDS 1 October 2025, pages 32 to 33), Zurich Wealth Protection (PDS 1 November 2025, Definitions and claims sections), NEOS Protection (PDS 6 December 2024, page 67), ClearView ClearChoice (PDS May 2024 with update 5 June 2025), Encompass Protection (PDS 26 September 2025), Acenda Insurance (PDS 27 September 2025) and Futura Protection (PDS 1 October 2025) all carry equivalent provisions.
Attending an examination the insurer reasonably requires is a policy obligation. Refusing without good reason can lead the insurer to decline the claim or suspend assessment.
What the examiner does
The specialist conducts a single appointment, reviews the file the insurer sends them, takes a history from you, and performs a physical or psychiatric examination as relevant. They then write a report to the insurer.
Typical issues addressed:
- Whether the diagnosis on the file is correct or requires revision.
- Whether maximum medical improvement has been reached.
- What treatment options remain.
- The functional restrictions that follow from the condition.
- Whether the insured can perform the duties of the relevant occupation.
Where IME concerns have been raised
ASIC's Report 498 (October 2016, 'Life insurance claims: An industry review') found instances where insurer behaviour around medical evidence had operated against the interests of claimants. The practice of repeat retention of the same examiners attracted criticism.
The 2018 Royal Commission into Misconduct in the Banking, Superannuation and Financial Services Industry (the Hayne Royal Commission) examined life-insurance claims handling in further detail. Post-Royal-Commission reforms tightened claims-handling standards. Claims handling is now a financial service requiring authorisation, since 1 January 2022.
Practical points an examiner's report should be read against:
- The examiner usually sees the claimant for a single appointment, against treating specialists who have seen the claimant over months or years.
- Treating-specialist evidence carries weight under the policy 'all relevant medical and other evidence' wording. An IME does not automatically override treating opinion.
- Conflicting reports are common. The assessor must weigh them and document the reasons for the conclusion.
Practical tips for attending an IME
- Read the appointment letter. It will name the specialist, the location, the date, the topics to be covered, and any documents the insurer is providing to the examiner.
- Take a support person. They can take notes. Some practitioners permit recording; ask in advance.
- Be accurate, not heroic. Describe what you can and cannot do truthfully. Examiners take note when claimants understate or overstate functional capacity; both extremes hurt credibility.
- Bring your own documentation. A current medication list, a recent treating-specialist letter, and a summary of treatment history help avoid gaps.
- Ask for a copy of the report. Under the Privacy Act and APP 12, you have a right to access personal information held about you. The insurer's claims team will usually release the IME report on request, sometimes with redactions.
- Show the report to your treating specialists. If the IME report contains findings your treating doctors disagree with, ask them to respond in writing. The supplementary letter goes into the claim file and the assessor must consider it.
If the IME report is the basis of a decline
Lodge an internal dispute resolution complaint. The complaint can attach the supplementary treating-specialist responses to the IME findings.
If the IDR outcome is unsatisfactory, the matter can escalate to AFCA. See:
For the wider documentation picture see what medical evidence is required for a TPD claim and the TPD claims process.