If you’re receiving long-term disability (LTD) benefits, you may be wondering: Can my insurance company force me to have an independent medical exam for my disability claim? The answer is yes. Under most LTD insurance policies, your insurer has the right to request an Independent Medical Examination (IME). But just because it’s allowed doesn’t mean the process is fair.
IME assessments are one of the most common tools used by disability insurers to evaluate ongoing claims. But many claimants are blindsided by how biased and damaging these assessments can be. Here’s what you need to know about independent medical exams for disability claims.
What are long term disability benefits?
LTD benefits are an income replacement benefit intended to provide a portion of your income should you become disabled from working. Your LTD policy will provide the particular benefit amount. It could range from 50% to 80% of your income, depending on your plan.
The LTD policy is meant to be a “peace of mind” agreement, meaning the insurance is supposed to help provide a monthly income if you’re unable to work due an illness or injury.
For the first 24 months, your LTD insurer will determine whether your medical condition prevents you from completing the essential duties of your own occupation. After 24 months, the definition expands, and the insurer evaluates whether your medical condition prevents you from performing the essential duties of any occupation.
How is your claim evaluated by the insurance company?
If you’ve been approved for long term disability, your insurer may want to set you up with an assessment. LTD case managers have tools available to them to help the insurance company evaluate your claim. The case managers can request medical records, interview you on the phone regarding your condition and have access to online medical resources to help them understand your condition better. One of the most implemented tools is the Independent Medical Examination (“IME”).
What is an Independent Medical Examination (IME) in a disability claim?
An Independent Medical Examination in a disability claim is a medical assessment requested by your LTD insurer. If you’ve been provided with a diagnosis and your insurer is unsure of the limitations with your medical condition, they’ll likely schedule an IME.
If your medical issues mainly stem from a mental condition, your insurer will likely schedule a psychiatric IME. If your medical issues are mainly physical in nature, your insurer would likely schedule you for a physical IME (like a functional capacity evaluation).
Beware! While the IME is supposed to help the insurance company adjudicate your claim, there is more happening behind the scenes. IME’s are scheduled with doctors hired by the insurance company, often someone they’ve worked with many times before. These doctors are paid directly by the insurance company.
This all screams – bias! It is common for the IME doctors to misconstrue information you’ve provided. It’s important to be cognizant of how you present during the assessment. Most likely, the assessor is taking notes on what you are saying and doing during the assessment.
Can I refuse an Independent Medical Exam?
In most cases, you are required to attend the IME examinations. Refusing an IME can result in your LTD benefits being terminated. Your policy most likely includes a clause that requires you to participate in evaluations that they deem “reasonable”.
When are IME’s usually scheduled?
Mostly commonly, IME’s are scheduled:
- As the change of definition period approaches (around 18-24 months into your claim). This usually triggers the LTD insurance company to schedule an IME. If there is no drastic change or improvement in your medical condition, the insurer will want information to determine whether you meet the “any” occupation test under the policy.
- When your insurer questions the validity or severity of your diagnosis.
- As part of a reassessment process if you’ve been on claim for an extended period.
I did the IME, now what? What happens after an Independent Medical Exam?
The IME assessor will send a report based on their findings to your insurance company. You have the right to request a copy of the IME report. If the report is supportive of your condition, your benefits will likely continue. If the report is not supportive of your condition, your benefits will likely be denied.
It is common for the IME reports to disagree with your doctor’s findings (or vice versa) and medical notes provided to the assessor. In fact, LTD denials after an IME regularly occur.
The IME doctor says I can work, but I can’t
If your disability claim is denied after an IME, and you still cannot work due to your condition, then it is time to get a disability lawyer involved. An experienced disability lawyer can challenge the IME findings and take any necessary steps to ensure you receive your rightful benefits under the terms of your policy.
Denied LTD benefits after an IME? Let us help.
In short, yes, the insurance company can force an independent medical exam for your disability claim. If you underwent an IME for long-term disability and your provider denied your LTD benefits on the basis of the IME, call us. If you have any questions about how to respond to an IME request from your insurer, reach out to the disability team at Whitten & Lublin. We understand the tactics the LTD insurance companies use, and we know how to fight back to put the power back in your hands.
We offer free consultations for short- and long-term disability claims. Contact us online or call (416) 640 2667.
Author – Aman Chaggar
