A doctor examining a woman's shoulder and arm

Medical Examinations for Long-Term Disability Claims: What to Know

What is an Independent Medical Examination?

An Independent Medical Examination or “IME” is an assessment that is arranged for you by your long term disability insurance company. In most long term disability insurance policies or plans, the insurance company has the right under the policy/plan to send a claimant to a doctor of the insurer’s choosing for an examination of either physical or psychological issues.

This could happen at any time during the claims process, however, it is more common for an IME to be conducted at the outset of the claim to determine entitlement or leading up to the change of definition (the change of definition is when the definition for disability under the policy changes from the “own occupation test” to the “any occupation test” and this usually happens at the 24-month mark). 

The IME doctor engaged by the insurance company will not provide you with treatment and this may be the first and last time you ever see the IME doctor. The role of the IME doctor is to provide an opinion to the insurance company on your symptoms and your restrictions and limitations. The IME doctor may also be requested by the insurance company to provide an opinion on your level of disability, treatment recommendations, and your diagnosis and prognosis.

Can I refuse to attend an Independent Medical Examination?

Often your long-term disability insurance policy/plan will contain provisions that require you to attend an Independent Medical Examination and may allow the insurance company to terminate your benefits if you fail to attend the examination.

It is better, therefore, to attend the Independent Medical Examination and dispute the outcome at a later stage than to refuse to attend, which may provide the insurance company with immediate justification to terminate or deny your long term disability benefits claim.

Will the IME doctor ask me questions about my medical history?

Although the insurance company will typically send medical records that they have on file for you to the Independent Medical Examiner, the insurer may not have all relevant medical documents applicable to your medical issues. At the time of the evaluation, the Independent Medical Examiner may not have reviewed all the medical records he or she received. It is likely, therefore, that you will be asked several questions about your medical history.

If there is something in your medical history that you cannot specifically recall, advise the examiner accordingly. If you are unsure of the details, it is better not to guess as this can impact credibility if it turns out that you are inaccurate. It is also important to answer what you are being asked and not to volunteer information beyond what you are being asked to provide. It is useful to make notes of your experiences in the Independent Medical Examination.

Will the IME doctor examine me?

The purpose of the Independent Medical Examination is for the assessor to examine you. If your disability is physical, the examiner may wish to assess your ability to perform certain functions such as sitting, standing, walking, bending, kneeling, squatting, etc. The assessor may wish to examine parts of your body to determine whether you have issues with range of motion or pain. If you are dealing with a mental health issue, you may be required to complete certain psychometric tests which will then be assessed and interpreted.

IME assessors are often asked to conduct validity testing. For example, in physical examinations, they may be looking for a mismatch between physical findings and symptoms reported and may conduct certain tests to determine whether there are inconsistencies. In psychometric testing, they may have you complete assessments that are designed to determine whether you are malingering or exaggerating.

How should I interact with the IME doctor?

The first thing is to ensure that you are on time for the assessment, arriving late creates a negative impression and may limit the time that the IME assessor has available to meet with you which could impact the assessment.

Be aware that you are being observed and monitored from the moment that you arrive to the time that you leave the appointment.

Adopt a pleasant demeanour when you are engaging with the assessor and avoid being confrontational or combative in your interactions as this will only work against you.

Answer questions that you are asked, do not volunteer information that has not been requested from you. For instance, if the assessor has not asked you questions about issues in your workplace, do not volunteer information about all of the negative experiences you may have had in your workplace.

Can the insurance company deny my claim based on an IME assessment?

Not all IME assessors are created equal and some may be used more frequently by insurance companies because their opinions are often more favourable to the insurer. They may frequently determine that there is an absence of disability or acknowledge disability but indicate that an accelerated recovery has occurred.

It is not uncommon for insurers to deny claims where an IME assessor has determined that the insured is not disabled or no longer disabled. There is a common misconception that the insurance company always sends a claimant to an IME assessment in order to confirm entitlement. Sometimes, however, the insurance company may be sending a claimant to an IME in order to dispute entitlement to long-term disability benefits.

Am I entitled to receive a copy of the IME report?

A claimant has a right to receive a copy of the IME report and often an insurer will send a copy of the IME report to the claimant’s treatment providers.

If you receive a copy of the IME report and you disagree with the contents of the report, have your family physician or specialist prepare a rebuttal to the report explaining why he or she feels that the report is inaccurate. The rebuttal is most effective if it comes from a doctor with the same or similar specialty.

Your doctor or specialist should specifically outline the reasons the IME report is inaccurate or deficient and provide substantiation for his or her opinions. Remember that the Independent Medical Examiner sees you on one occasion whereas your treatment providers have seen you regularly and have an intricate understanding of the nature and evolution of your medical issues. They may also be familiar with how you were before your disability arose and can provide useful information when explaining decreased functionality leading to an inability to work.

Surveillance and the Independent Medical Examination?

Given that the insurer has arranged the Independent Medical Examination, they are aware of the date, location, and time of the assessment. As a result, the medical examination date presents the perfect opportunity for the insurance company to initiate surveillance. It is fairly common for insurance companies to arrange for surveillance to be conducted on the day of the Independent Medical Examination. The insurance company will usually instruct investigators to observe you both before and after the medical examination.

They may be looking to see whether you go anywhere after the IME and contrast your presentation on surveillance with what you may have told the Independent Medical Examiner.

For instance, you may have told the Independent Medical Examiner that you struggle with social phobia and barely leave your house. If you spend the rest of the day after you have attended the Independent Medical Examination running errands and attending various stores and locations and your activities are observed on surveillance, that could impact your credibility with the insurance company. The insurance company may send the surveillance footage to the IME doctor before he or she completes his or her report.

Insurance Companies may also arrange for surveillance to be conducted before an Independent Medical Examination and send that surveillance footage or surveillance report to the IME doctor before the assessment.

The most important thing to remember when attending an Independent Medical Examination is to always be honest and as accurate as possible when explaining your symptoms, restrictions, and limitations. If your claim is denied on the basis of an opinion contained in the Independent Medical Examiner’s report, there are many ways to contest the denial.

If your long term disability claim has been denied due to an Independent Medical Assessment or for any other reason, you should discuss your long-term disability claim with an experienced lawyer. MK Disability Lawyers LLP are experienced lawyers dedicated exclusively to the practice of disability insurance litigation. We would be happy to provide you with a free consultation.  Please contact us online or by calling us at 844-697-4600.

The preceding is not intended to be legal advice.  This blog is made available for educational purposes only as well as to give you general information and a general understanding of the law, not to provide specific legal advice.  By using this blog, you understand that there is no solicitor-client relationship between you and the blog publisher.  The blog should not be used as a substitute for competent legal advice from a licensed lawyer in your jurisdiction.  If your disability claim has been denied and you require legal advice, contact a lawyer specializing in disability law.