Medical Examinations for Long-Term Disability Claims: What to Know
Many individuals receiving long-term disability (LTD) benefits will at some point be asked to do an independent medical examination (IME). Most LTD policies contain provisions that require you to cooperate with the insurance company in their assessment of your claim. This includes the right to send you to a doctor of the insurer’s choosing for an examination of either physical or psychological issues.
You can be asked to do an IME at any time during the claims process. However, the assessment is typically performed at the beginning of the claims processes to determine entitlement or leading up to the change of definition, which usually happens at the 24-month mark.
What is an independent medical examination?
An IME (also referred to as an independent medical evaluation) is a medical examination performed by a healthcare practitioner that does not have a prior treating relationship or any connection with the person being assessed. It is an assessment arranged and paid for by your insurer or disability plan administrator. The purpose of the evaluation is to determine if the individual receiving benefits is disabled and cannot work.
The doctor conducting the IME will assess your ability to function and respond physically and/or mentally to various tasks. The examination itself and how long it takes will differ based on the nature of the assessment. For example, physical assessments, also called functional capacity assessments or functional ability evaluations, may take one or two days to complete. In some cases, the assessor will conduct the interview and perform a thorough examination and testing during the same appointment. Certain conditions may require the assessor to do the physical assessment over two days. The examining physician may recommend limiting your ability to perform daily activities at home, work, or in recreation based on the extent of your injuries.
Common types of IME services
IMEs are common in Canada and often requested by insurance providers, employers, and long-term disability lawyers. The exam may occur at any time during your recovery. In some cases, regular IMEs are required. The time it takes to book an IME depends on the type of evaluation and the availability of the specialist required.
Functional Capacity Evaluation
The examiner will conduct a variety of tests to assess a person’s physical and functional abilities. It includes an evaluation of strength, endurance, speed, flexibility, and other abilities required for a given job.
Cognitive Abilities Evaluation
A Cognitive Abilities Evaluation (COG FCE) includes tests and observations used to determine cognitive strengths and limitations, including attention, memory, planning, problem-solving, behavioural changes, and fatigue. This form of evaluation is particularly useful for traumatic brain injuries or concussions.
The physician will investigate the existence, nature, and degree of mental and behavioural disorders. In some cases, the psychiatrist or psychologist may conduct interviews with the person’s family doctor, family members, employers, or others if required.
Physical Medicine Assessments
Physiatrists specialize in evaluating injuries to the musculoskeletal system, including muscles, bones, and associated nerves, ligaments, and tendons. Depending on the injury or condition, the physiatrist will conduct medical/diagnostic tests, question and answer evaluations, and physical assessments to determine any impairments that exist.
It’s important to remember that the medical expert performing the exam is classified as a consultant and not your personal care physician. However, the examiner may comment on treatments you should undergo or medications you should take. These recommendations will outline the terms and conditions of the disability policy and benefits with your insurance provider.
Will I need to answer any questions about my medical history?
Typically, the practitioner performing an IME is provided with any relevant medical records and reports from your treating physicians, including your family doctor. Some assessors require additional information before conducting the exam. You will likely be asked questions about your injuries, medical history, current pain areas, and abilities (or limitations) to function through daily activities.
If there is something in your medical history that you can’t recall, let your examiner know. If you are unsure of the details, it’s better not to guess, as this could impact the credibility of your claim if it turns out that the information you provided isn’t accurate. It’s a good idea to consult with a long-term disability lawyer before your assessment to review the type of information you will be asked to provide.
Can an insurance company reject my claim after an independent medical examination?
The IME report is often used by an insurer to confirm or deny benefits, coverage, or settlements to the claimant (the individual making a long-term disability claim). It is not uncommon for an insurance provider to deny claims if the IME assessor determines the claimant is not disabled or no longer disabled. If you disagree with the conclusions of the IME report, have your primary physician or specialist prepare a rebuttal to the report explaining why the assessment isn’t accurate.
When there are differences of opinion regarding your condition, the insurance company will typically side with the report they determine to be most credible. Unfortunately, this report is usually from the IME doctors they hire. This means that it may be difficult to recover benefits, but it doesn’t mean it’s impossible. An experienced long-term disability lawyer will investigate ways to fight the IME report if you feel it’s inaccurate.
Can I see the report of my independent medical examination?
As the claimant, you have the right to receive a copy of the IME report. The general rule is that a physician must provide an examinee with access to personal information contained in the IME file upon request. After the assessment, you need to ask your case manager or insurance adjuster for a copy of the report. Some insurers may send the report directly to your treating doctors. Be sure to notify your primary physician of the assessment and let them know that you have requested a copy of the report. This will help expedite the process of disputing the medical assessment if the IME practitioner contradicts the conclusions of your doctor.
If your long-term disability claim has been denied because of an independent medical examination, there are ways to contest the denial. An experienced long-term disability lawyer can protect your interests by filing objections or requesting another examination to dispute the IME report. If you would like to speak to a long-term disability lawyer at Valent Legal to learn more about your legal rights or for legal advice on how to handle your disability claim, schedule a free consultation today.