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Mar 06

Defending Your Claim Against the Insurance Company IME

The most important piece of evidence in a disability claim is the medical basis for the disability.  If there is strong medical proof of the severity and continuation of your disabling condition, then there’s a good chance of your claim getting approved.  However, this may not always be the case.  Many conditions don’t have clear cut tests to prove their existence, and other conditions have testing protocols that either aren’t generally accepted or aren’t always accurate.  Even if appropriate testing exists, claims examiners may try to dispute the opinion of the attending physician.

When these and other issues are noticed in the claim file and want to be explored, claims examiners will often demand that the claimant undergo an IME.  Most disability policies provide the right for the insurance company to have a physician of its own choice examine you and can require an IME – an Independent Medical Examination or Independent Medical Evaluation, depending on the policy language.  Depending on the nature of the claim, some claims examiners may ask that a claimant undergo a Functional Capacity Examination.  FCE’s are a very different and frankly more dangerous process for claimants and will be addressed in another blog post.

Undergoing an IME can be a nerve-racking and daunting process.  Going to a doctor whom you don’t know is hard enough, but the knowledge that the examination could cause your benefits to be denied amplifies the feelings of fear and intimidation.  The good news is that there are strategies to undergo an IME and still defend your rights.  The first step to learning these strategies is to understand the reasoning behind the insurance company’s demand for an IME.  The disability claim process has three stages when IME’s are commonly requested:

  1. The beginning of the claim.  If the insurance company demands an IME at the beginning of your claim, the claims examiner has information that your disability claim doesn’t match your medical information.  They suspect that you’re claiming an incorrect diagnosis or that your symptoms and limitations are exaggerated and overstated.
  2. The transition from an “own occ” to an “any occ” definition.  If you have been receiving benefits based on a definition of the duties of your own occupation and the policy terms are about to change to the duties of any occupation based on your education, training, and experience,  the claims examiner may request an IME to support their assertion that you’re able to work in another occupation.
  3. If your condition isn’t getting better.  Insurance companies use confidential and proprietary guidelines for the expected duration of the treatment of most conditions, the time that a claimant should receive benefits depending on the medical condition.  If your disability claim goes longer than expected, it’s common for an IME to be demanded.

If you’re approaching or in any of these stages, you might receive a request for an IME in the near future if not already.  With this realization, it’s important to know what you are walking into.  It sounds harsh, but IMEime‘s are not going to be favorable to your claim – you can only reduce the ways in which the IME can be harmful.

One quick warning about the how insurance companies have turned the “I” in IME’s to their advantage.  IME physicians aren’t directly on the payroll of the insurance company.  Many IME’s are scheduled through third party vendors, which do volumes of this type of work for insurance companies, who recruit and pay doctors to do IME’s.  The IME vendor’s contracted doctor is then briefed by the insurance company with an inherent focus on the problems in the claim – the provided information and documents can be pruned to highlight those problems.  It becomes obvious what the desired opinion is.  “Good” IME companies and doctors are those who reliably can come up with medical reasons why claimants aren’t disabled and write fast, favorable reports for the insurance company.  So, IME doctors have logical business reasons to reach the opinion favorable to the insurance company – and detrimental to your claim.  

However, this doesn’t mean there’s nothing you can do.  There are several steps you can take and tips to follow to help protect your rights and your benefits: 

  • Come prepared.  Before your IME, sit down and prepare a brief outline of the history of your medical condition(s).  Include details such as where, when, and how the issues started, any similar problems, etc.  If you can take pictures of your medical conditions, bring those to give to the IME doctor.  Broadly summarize your treatments – what’s worked, how it’s specifically helped, etc.  Bring your medical history document with you.  If you are unfamiliar with medical history documents, please read this prior article.  
  • Bring a witness and record the exam.  If at all possible, do not attend an IME alone.  If you have an attorney, plan on them attending the IME.  If not, take a friend with you to the IME to observe what was done or said and make copious notes.  Have them take accurate notes, as many and as detailed as possible.  Make notes of exactly what tests are done and how they were done.  Keep track of the times taken.  Specifically note any informal comments made off-hand by the IME doctor.  See if you can record the IME using a digital recorder.  Even if you don’t specifically get permission to record the IME, you might want to discretely do it to review later to aid your notes.  These notes will be extremely important in responding to the IME report later in the disability claim process.  Take someone who is fairly assertive and won’t have a problem asking for a break if you’re becoming fatigued or just want a break.  Yes, you can take a break if and when you need one.  An IME shouldn’t be an endurance contest.  Your friend is there to protect your personal needs during the IME and document what actually took place.
  • Be honest, thorough, and cooperative.  Although you may not like having to go through the IME process, misleading or being uncooperative with the IME doctor won’t help and can even increase the risk of losing your benefits.  This can be another use for your medical history notes, mentioned above.  When describing your pain and limitations, try to avoid using words such as “always” or “never,” which imply your conditions never change.  Be more descriptive and specific when and how certain tasks affect you.  If the IME doctor asks you to perform certain maneuvers, attempt them.  But if these cause any discomfort, quickly and clearly tell the doctor –  but don’t exaggerate the pain.  IME doctors often include certain tests that shouldn’t hurt just to test the veracity of the responses.  Functions are usually tested in several different ways, so inconsistent pain or a so-called “lack of effort and motivation” can be cited to discredit your claim.
  • Be aware of your surroundings.  On the days before, after, and of your IME, try not to engage in any unusual or challenging activities.  Always use common sense, and be aware of your activities and surroundings.  Disability insurers often arrange video surveillance during these days.  Whatever you’ve reported about your physical and mental capacities to the claims examiner should be consistent with what you tell the IME doctor, and should also match any activities that might be recorded on the days around the IME.  Be wary of surveillance while waiting for the IME.  Some companies have the staff at the IME doctor’s office “watch” you in the waiting room and document any inconsistencies.  Remain aware of anything unusual or out of place while traveling to or from the IME.  If you would like to learn more about insurance company surveillance and how to counter their tactics, you can read our article here.

surveillanceIt’s critical to understand that the IME doctor is not examining you to give you medical advice.  He (or she) is not there to discuss or recommend different treatments options for your conditions.  IME doctors will usually not put your explanation of what’s really disabling you into their notes and will try to use questions that only allow “yes” or “no” answers.  It’s human nature to want to explain your situation, want to be believed, and have faith that the doctor examining you is sincere in his (or her) actions.  However, please understand that the designated role of the IME doctor is to be cynical of any claims and come up with opinions to support the insurance company’s questions.  Don’t ask the IME doctor any medical questions about your impairments or your treatments.  It’s highly unlikely you’ll be provided with anything substantial – that’s simply not the purpose of the IME.

It’s no surprise that not too many IME reports support continuing disability.  The decision to deny the claim has often already been made by claims examiners and it’s just a matter of figuring out how to come up with reasons for the denial – although disability insurers will vigorously insist that’s not the case.  In most claims, claims examiner have been working with their in-house medical, financial, vocational, investigative, etc. resources to generate information and documents that support the denial.  IME’s are one of their steps in a long series of actions focused on documenting that you’re not entitled to disability benefits.

Your IME doesn’t have to be a nightmare.  Go into the IME with confidence, follow the tips above, and be prepared.  The IME doctor and the claims examiner are going to do what they’re going to do.  It’s your role to understand this and prepare your response for this part of the disability claim process.  If you have any questions or concerns about an IME, please visit our website to sign up for a free consultation or call our offices toll-free at (855) 828-4100.

2 pings

  1. Royal Claims Advocates

    [...] handle and neutralize the inherent bias in an FCE.  Some of the best tips are the same as in our article on IME’s: bring a witness to record and make copious notes during the examination.  FCE’s are often [...]

  2. Medical Disability Durations & The Effect on Return to Work Guidelines | Royal Claims Advocates

    […] Our firm has successfully used several different techniques to combat these issues, and many of these answers can be found in previous blog posts. The first defence is to create a complete and thorough job description and make sure it accurately reflects your actual duties – more information on this topic can be found here. Fighting the disability guidelines is a more difficult process that relies on copious medical records and doctors who are willing to fight for their opinions. Insurance companies often contact doctors without any sort of notification to the patient-claimant and try to influence doctors to change their opinions on their patient’s ability to work, especially if the expected claim duration has been exceeded. You need to be in regular contact with your treating physician(s) to make sure they understand your job demands and your symptoms and to make sure they’re not being harassed by anyone from the insurance company – claims examiners, investigators, or even other doctors. We’ve seen doctors change their opinions just to stop the hounding by the insurance company, regardless of the actual condition of their patient. We have several posts on dealing with aggressive claims examiners, helping your doctor help you, and defending yourself against the medical examinations demanded by the insurance companies. […]

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