As disability questions go, this one is a doozy: are “independent” medical exams truly independent?
To answer that question, you first need to know what I’m talking about. When you make a disability claim with your insurance company, there’s a good chance that you’ll be doing so with a statement from your doctor describing the issue that you have. This is your proof — your evidence — that you are suffering from a disability.
Most claimants don’t even think past that. They figure that if a medical doctor has signed off saying they have a disability, that’s the end of the story. But any disability attorney will tell you that insurance companies aren’t just going to pay based on the word of your doctor. Chances are, they will want to schedule more appointments with their disability insurance doctors. These are called independent medical exams.
This evaluation is scheduled with the insurer’s chosen medical doctor, a third party previously not involved in the case, and who is employed by or contracted by the insurer.
What is the IME For?
The goal of the independent medical examination is to investigate the degree of disability and whether information exists to support a decision to deny benefits.
Theoretically, results from the IME should establish credible medical evidence that the insurance company would use to dispute the claim, reduce or deny the dollar amount of disability benefits, and to detect possible malingering.
The general thinking is that your own physicians will uphold that you are disabled because they (1) have already provided statements and medical evidence that you are disabled, and (2) have developed a history with you and are providing ongoing treatment and care.
So the insurance company has the right to have a fresh pair of medical eyes examine you.
How Independent Are These Exams?
That’s the big question about independent medical exams: what exactly is independent about them? Theoretically, they are supposed to be conducted by doctors who have no stake in the outcome.
Sounds fair, right? But it isn’t. The Independent Medical Exam is hardly “independent.” The process is not always autonomous nor are the examining doctors always impartial. Most of the time, the IME is only good for the disability insurance company, and not good for you, the disabled claimant.
These “so-called” independent disability insurance doctors are not only in the network of your insurance company (you didn’t think they’d send you to someone who wasn’t covered by their plan, did you?), many of them actually advertise to the insurers that they can help them keep their costs down by disputing claims. It’s good for the doctors because they get money from the insurers for seeing you, and good for the insurers because they have an expert opinion that can argue against your claim.
An entire medical industry has been built around disability insurance IMEs. These practitioners do nothing but perform independent medical exams, paid for by insurance companies, day in and day out.
The only person it’s not good for? You.
IME doctors may not be prepared or inclined to properly assess complex medical restrictions or combinations of disabling impairments for each unique claimant. Even with the proper training and background, an IME doctor, in one or two visits, can do more harm than good to your disability case.
You Must Attend the Independent Medical Exam
Most disability policies will contain a clause requiring cooperation with the IME. When this provision exists, one needs to attend the exam or risk claim denial. A claimant can be ordered to submit to an IME “as often as reasonably required” if that is how the policy reads.
The IME provision will vary from policy to policy, and instructions can be vague or specific about the extent of the exam or type of assessments to be allowed. Policy requirements regarding the IME doctor’s qualifications and accreditations may also be vague.
Consequently, disputes are common between insurer and policyholder as the arguable intent of the exam is for the insurer to save money, while the insured doctor or dentist hopes to be paid his rightful disability benefits.
What Evaluations Might Occur During the IME?
The examiner generally reviews all medical records and looks for objective manifestations of impairment that match any medical studies presented in the case file. He or she will also assess your subjective symptoms including pain, fatigue and other discomforts. Tests may be done that require you indicate levels of pain and sensitivity associated with your disabling condition.
Tests performed may include:
- Neuropsychological Tests – This group of tests examines brain function including motor performance, memory, attention and processing speed, abstract thinking, temperament, intelligence, problem solving, vision analysis, and executive functions. Neuropsych exams are subject to interpretation, and can be used by insurance companies to obtain results in favor of denial of benefits.
- Psychiatric and Psychological Tests – Various tests distinct from the neuropsychological tests may be done; again, these results are subjective in nature.
The examining medical doctor will evaluate other factors such as lifestyle, aggravating conditions or ongoing treatment. The doctor will also watch for signs of deception during the IME.
The examiner will prepare a report documenting that you are / are not capable of certain physical activities, including your ability to return to work in your occupation.
What Happens after the IME?
The next step in the insurance company’s “fact finding” process is often a Vocational Exam. The insurance company will forward the findings of the Independent Medical Exam to the resident vocational assessment expert – who will use the medical evidence as a basis for further vocational evaluation.
In addition to Independent Medical Exams, you may be asked to submit to a Functional Capacity Exam, which is a much more rigorous battery of tests designed to measure a disabled insured’s limitations.
Sometimes the insurance carrier will schedule a medical file review instead of the Independent Medical Evaluation. In this case, a hired or in-house physician simply reviews the claim files and medical records to make a judgement about the disabled claimant.
Fighting “Independent” Exams
The independent medical evaluation is about risk management on behalf of the insurer. A third party is being paid to reinforce in-process decisions to discredit long term disability insurance claims.
Over the years, our attorneys have observed how certain insurance companies attempt to game the IME process in order to establish that the claimant is
- not disabled at all; or
- only partially or residually disabled
A good disability attorney knows this going on and knows how to argue against the findings of these “independent” examiners, so it’s wise to get an expert on your side if the insurance company attempts to block your claim.
If you have more long term disability questions, visit our website and see how we can help you.