“Independent” Medical Examinations: Insurance Companies’ Best Defense

This article explains the concept of Independent Medical Evaluations (IMEs) as used by insurance companies to deny, delay, or complicate providing medical coverage after a workplace accident. It discusses:

• What a defense IME is and how insurance companies use them to deny coverage,
• How they are different from a regular medical examination and why you cannot really refuse them, and
• What to do to prepare for a defense IME or how to deal with a conflict between them and your doctor.

What Is A Defense Independent Medical Examination In The Context Of Workers Compensation?

IME stands for independent medical evaluation and the North Carolina Workers’ Compensation Act allows any insurance company to request one. They can demand a worker undergo an IME if the worker is requesting any kind of compensation, notably medical or disability coverage. If you want any kind of compensation later, you really have no choice but to comply.

While North Carolina’s statutes clarify that doctors used for an IME should be local and independent, there is a disturbing trend of insurance companies requesting specific doctors for IMEs in their own specific interests.

Why Do Insurance Companies Request An IME?

What careful observation shows over the years is that defendants (i.e. insurance companies) use the IME statute not to get an independent evaluation of symptoms and conditions, but to start building their case against the injured worker. Hence the term defense IME.

The insurance company will often have an injured worker be ordered to attend an IME, sometimes as far as over a hundred miles away, because they want specific doctors to see the injured worker. Doctors who they think will be helpful to the defense’s cause rather than to the plaintiff’s cause. The continued use of the term “independent” is certainly up for debate.

Unfortunately, the industrial commission seems not to be concerned about whether or not defendants are using these IMEs for defense witness expert discovery and tactics against injured workers’ claims and health. The IME has been turned into a medical appointment that defendants are using to support their own case. They are often with doctors that insurance companies like or have a relationship with, hopeful that the doctor will limit treatment recommendations, disability ratings, and work restrictions.

Which is why insurance companies love to request them so much.

How Is A Defense IME Different From A Treating Physician’s Medical Evaluation In A Workers’ Compensation Case?

When dealing with a defense IME, it is important to understand what makes them different from an ordinary treating physician’s evaluation.

Your treatment physician is the doctor that the insurance company will find to treat your injury after a workplace accident. There are some limitations on who they can choose. It is expected by the industrial commission that the treating doctor be somewhat local. Insurance companies are, at least in theory, not allowed to force an injured worker to drive from one side of the state to the other in order to see their doctors.

Treating physicians are supposed to be local and more convenient in order to get treatment going quickly. The same logic applies to physical therapy visits. No one wants injured workers to travel across the state just to get a physical therapy appointment. Both would certainly impact your ability to return to work. The treating physician is designated by the insurance company to provide that frontline treatment.

IMEs, on the other hand, are usually engaged by insurance companies to get an opinion on a very specific medical issue or question. Some examples of these questions could include:

• Is the surgery that the treating physician is recommending really necessary?
• Is there a better or cheaper alternative to the treatment that the physician is requesting or recommending?
• Is the treatment being recommended by the treating physician even related to the work injury or is it too hard to tell based on the information being provided?

IMEs are generally one-time appointments that insurance companies use to get a few questions answered and start to build a case against you. They might be trying to support a denial of the claim, support a denial of the ongoing medical treatment, or get you back to work as soon as possible. They want to get you on your way quickly instead of opting for more conservative treatment recommendations.

Can I Refuse To Attend A Defense IME Requested By An Employer Or Insurance Company?

You are always allowed to refuse a medical examination, but doing so could very well have serious consequences on your workers’ compensation claim or medical treatment coverage. So, in practice, you do not really have a choice.

Once the industrial commission allows an insurance company to request an IME, if you refuse to attend, your case will be put on hold until the refusal ends. So while, based on the IME statute in the Workers’ Compensation Act, you can always refuse to be seen by any doctor, doing so is not really an option.

Refusing could complicate or even prevent the case you are trying to pursue from moving forward. A better method could be explaining to the insurance company why this doctor might not make sense or is unreasonable. With the help of your workers’ compensation attorney, you can negotiate to agree upon a doctor you can actually see where both sides will believe that they are getting good advice that is not slanted one way or the other.

What Happens If The IME Physician And The Treating Doctor Are In Conflict?

Inevitably, situations arise when the treating doctor and the IME doctor, despite both being chosen by the insurance company, enter into conflict over your treatment. When this happens, there are many possible paths and outcomes.

You can argue that you don’t really care what your defense IME says, the insurance company chose the treating physician and they say you need the surgery. Therefore you expect them to authorize it. The company then has to make a decision. Do they think the IME provided sufficient grounds to deny coverage?

It is, unfortunately, common for there to be an administered negotiation between the injured worker and the insurance company about which doctor’s recommendations seem to make the most sense. When the injured worker and the insurance company are in conflict, several things can happen. You can request your own IME, the insurance company might request a second IME themselves, which could escalate to a full battle of the experts.

And, of course, either the insurance company or the injured worker can always request a hearing and have the industrial commission make a decision to sort out the conflict.

How Can I Prepare For A Defense IME In A Worker’s Compensation Case?

It is difficult to say what you should expect from an IME, much less how to prepare. Some doctors will treat IMEs just like any other patient, in which case all you need to do is show up with your imaging studies. You’ll probably wait in the waiting room and then have a conversation with the IME doctor after an exam and review of your history, just like they treat all their other patients.

Then, reportedly, there are times when the IME doctor treats an injured worker far worse or with much less compassion and sympathy than they would another patient. This may be deliberate to get you to make a mistake. Either way, you will have to bite your tongue, avoid becoming defensive or aggressive, and try to be accurate. Hopefully, you can get the IME doctor to respect you and listen to you. Your goal is for them to include nothing in their records that is inaccurate or is the result of the doctor not being fair with workers’ compensation cases.

If you believe they might have been unreasonable or unfair, consult with your workers’ compensation attorney immediately, as this could be relevant to your case and its outcome.

For more information on Independent Medical Evaluation During Workers’ Compensation Claims, a free initial consultation is your next best step. Get the information and legal answers you are seeking by calling (833)444-4127 today.