The Role of an IME in a Disability Insurance Claim

It seems grossly unfair that when you’ve been paying premiums for private disability insurance, the insurance company treats you with disdain and suspicion when you file a claim for benefits. Unfortunately, it’s all too common. Insurers are happy to take your money but very reluctant to live up to their obligation to pay when the terms of your policy entitle you to benefits.

One of the ways insurance companies make it difficult for policyholders to obtain disability benefits is to require them to submit to an IME or Independent Medical Examination. Oftentimes, this exam is not at all independent, and it is used as a tool to deny claims.

For that reason, it is important to understand the role of an IME in a disability insurance claim and understand what to do to protect your interests.

What Happens During an IME

An IME is an examination conducted by a doctor or other medical professional who has not previously been a part of the patient’s treatment plan. The examination is supposed to give a fresh, honest perspective of a patient’s condition and prognosis.

Prior to the exam, the provider will typically review treatment records, but they may only look at certain records carefully chosen by the insurance company. During the exam, the provider will ask questions, examine your condition, and make notes about answers and observations. The provider may ask you to move in certain ways so they can assess mobility or evaluate other abilities.

After the exam is over, the healthcare provider will write up findings, including an opinion regarding your ability to perform regular functions needed to work. The opinions in the report will be used by the insurance company to determine whether you qualify to receive benefits under your disability insurance policy.

An Independent Medical Exam Can Be Far from Independent

The doctor or other healthcare provider who conducts your IME is hired by and accountable to the insurance company. While the provider may be new to you and may approach your case with a fresh perspective, their position often leaves them with a bias that can be nearly impossible to overcome.

The insurance company wants the doctor to find reasons that you are not qualified to receive disability benefits, so it is quite likely that the doctor will be looking for those reasons. It’s much easier to view facts the way you want to see them, so that undeniably colors the results of many IME reports. The report may highlight factors that point to your recovery and skip over factors that indicate you remain unable to work due to disabling conditions. That’s what the insurance company wants, so that’s what the doctor who works for them is likely to provide.

An IME is Not Designed to Help You

You have a relationship with your own doctor that establishes certain obligations. Your doctor wants to help you recover, and for that reason, your doctor will prescribe treatment and recommend actions that are in your best interests.

By contrast, the visit to the doctor for an IME is quite different. During an IME, the doctor may not be interested in taking the necessary steps to help your condition improve. Instead, the doctor is there merely to evaluate your condition without treating you. This type of doctor visit does not establish a doctor-patient relationship with obligations of loyalty and confidentiality. Statements you make during your IME can be used against you. It is very important to be careful with what you say and do during an IME to avoid giving the insurance company ammunition to unfairly deny your claim.

Honesty is Critical in an IME

In our society, we are trained to be polite and to do what we can to make others comfortable. For many people, that means putting a positive spin on a situation and making light of problems and concerns.

However, it is important to put aside these impulses during an IME. You need to be brutally honest. If you have to grit your teeth and steel yourself for pain every time you stand up, don’t try to hide it. While you don’t want to exaggerate the pain and discomfort you feel and the challenges you encounter, you also don’t want to downplay the problems. You need to let your genuine condition be readily apparent in everything you say and do during your IME. If something hurts, admit it.

The Report from an IME May Not Align with the Opinions of Your Own Physician

It is quite common for an IME to show that a policyholder is ready to return to work even when numerous other medical professionals have concluded that there is no way that policyholder should be attempting to work in their current condition. Of course, no matter how many doctors you have on your side, the insurance company is going to listen to the opinion of their own “independent” doctor and deny your claim.

So what happens then? It is a good idea to talk to an attorney who is experienced in handling disability insurance disputes. A knowledgeable attorney can review the case and look for weaknesses in the insurance company’s justifications. For instance, the IME physician may have cherry-picked through findings to highlight only those that favor the insurance company’s interests while ignoring evidence of continued disability. 

Pointing out the discrepancies in a letter or in negotiations may produce a reversal of the insurance company’s determination. If not, the arguments can be made in court to enforce the insurance company’s obligations and possibly show that the insurance company acted in bad faith so that the policyholder is entitled to compensation.

If You’ve Been Denied Disability Insurance Benefits, Talk to Ver Ploeg & Marino

The team at Ver Ploeg & Marino has been dedicated to helping policyholders get fair treatment from insurance companies for decades. We understand how the industry works and how to get results quickly and efficiently.

If you’ve experienced denials or unreasonable delays in your attempts to file a claim for benefits under your insurance policy, schedule a consultation with us and learn about the ways we may be able to work with you to ensure that your insurance company lives up to its obligations. To get started, call us at 305-577-3996 or contact us online now.

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