Why is my insurer demanding an independent medical exam?

Monday, October 14, 2019.

One of the most common questions we get is about independent medical examinations. You are limping along (perhaps literally) on disability, and out of the blue the insurance company wants proof that you are still disabled.

This is disheartening and scary. An unfavorable exam could cancel your benefits or force you to go back to work while you are ailing. Why is the insurer asking for an IME? Are you required to go?

The dreaded IME: Yes, you should be concerned

Most long-term disability insurance (LTD) policies contain a provision for independent medical exams (IME). Upon request, the insurance company can send you to an IME, during the initial application for disability or at any time while you are receiving disability benefits.

In theory, the purpose of the IME is to investigate your claim or to verify that your condition is still disabling. In reality, insurance companies use IME’s to undermine your claim to justify denial, reduction or termination of your benefits.

  • They don’t need a reason – There is no “probable cause” requirement. Insurers can send you to an IME at any time.
  • They are not interested in confirming disability – The insurance company is fishing for any reason to reject your claim or terminate your LTD benefits. The exam itself may be very cursory. The doctor’s questions are likely geared to downplaying your condition.
  • It’s not independent – In most cases, the “independent” physician who is performing the exam has been hand-picked by the insurance company. In theory, this is to assure that the doctor is qualified to assess your impairment and testify to their professional opinion. In reality, IME physicians consistently side with the insurers and conclude that the patient is not disabled or is no longer disabled.
  • Yes, you must submit to an IME – The policies and the law are quite clear. If the insurer schedules an IME, you must go. Failure to submit to the exam can result in the cancellation of your claim or termination of benefits. But you do have certain rights, including a detailed explanation for any denial or change in benefits. You also have the right to a medical second opinion if you disagree with the IME report.

We deal with this bias all the time

For example, Pillsbury & Coleman represented former NFL football player Charles Dimry, who filed for disability stemming from injuries suffered in his playing days. At trial, we prevailed in showing that the league’s IME doctor arbitrarily concluded that Mr. Dimry was not disabled, despite substantial medical evidence to the contrary. The court took the NFL to task for abuse of discretion in denying his long-term disability claim, which was essentially a finding of bad faith. He was awarded attorney fees and the league’s disability plan was ordered to re-examine the claim … with the expectation that an honest review of his case would result in an award of (retroactive) disability benefits.

That high-profile case is just one in a long line of similar denials. The independent medical exam is regularly weaponized by disability insurers to limit their payout of benefits. Our attorneys regularly fight insurance companies when they take advantage of disability claimants at their most vulnerable point.