Independent Medical Examinations and Your Insurance Claim

When an injury victim files an insurance claim for medical benefits, the insurance company, will challenge the claim by obtaining an Independent Medical Examination.  Most insurance companies maintain a list of "IME Physician Network" participants.  These physicians perform hundreds of medical evaluations each year for the insurance industry, which is a large part of their practice.  Their bias in favor of the insurance company is well known.  While you may view this as unfair, it’s a necessary part of the process and you should handle it by being prepared. 

How To Prepare For Your Independent Medical Examination

It is imperative to keep your appointment.  If you miss it, the insurance company may cut off your medical benefits.  Make sure to bring your medical records with you. 

The procedural rules governing Independent Medical Examinations (IME) vary among state jurisdictions.  However, several general requirements are universal:

  • The insurance company must give you reasonable notice of the time, place, and name of the IME examiner
  • They must outline the scope of the evaluation
  • The insurance company must reimburse the examining physician for the evaluation report
  • The IME physician is required to provide a copy of the report to you or your attorney within a reasonable time following the examination

The IME physician may be called to testify during a deposition and may be cross-examined at trial if your claim is litigated at a later date.  It is extremely important to be prepared for this examination and understand the objectives of the examiner.

What To Do During Your Exam

Under the law, you have to right to have a witness attend the exam with you.  However, if it is not a relative, the physician can deny their attendance.  Remember that this doctor is hired by your opponent and is paid to side with the insurance company.  When being questioned by the physician, try to reply with simple “yes” or “no” answers.  Do not elaborate or offer extraneous information.  Make sure that the doctor understands the amount of pain you are experiencing due to the injuries.  Always be polite, cooperative and truthful.

In most states, it is legal to record your exam with a voice or video recorder.  This will be useful evidence if the IME physician tries to falsify his or her report.  If you prefer, you can document your exam.  Be sure to include the time you arrive and leave the appointment.  Note how long the physician spends talking with you and actually examining you.  Once the exam is concluded, prepare a written summary of the exam.

How To Fight an Insurance Company Denial

If your benefits are cut off or denied by your insurance company as a result of an independent medical examination, you can try to resolve this through arbitration.  No-Fault Arbitration is designed to provide you and your insurance company with a method to resolve the dispute.  It is an informal process that is less costly and time consuming.  Each party is given the opportunity to present their side before a neutral third-party administrator.  However, it is limited to claims of $10,000 or less at the time of filing the claim.  The arbitrator is allowed thirty days after the hearing to make his or her award.  This award is legally binding on all parties involved and can be enforced by the courts.

Trial and Settlement

If your claim for benefits exceeds $10,000, you can choose to proceed with a trial where a jury will determine whether the insurance company will be held responsible for payment.  Choosing to settle the claim may make sense if your injuries aren’t substantial or require long-term treatment.  The insurance company will request that you sign a document releasing them from any future claims and that in exchange for this; they will pay you a lump sum of money to settle your claim.  Before agreeing to anything, you should consult with an attorney experienced in these matters.

 

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