JustHealth

Next Steps

            Once the IME results are forwarded to the insurance company, it is reviewed by in-house physicians who "rubber stamps" the tests as either valid or not valid. These reviewing physicians rarely offer medical opinions at this point since their only role is to lend credentials to the IME by commenting whether the exam was "good" or "bad."

            When the insurance company physician has reviewed the report, the claim file is returned to the claims examiner who will then send a copy of the IME report to your primary care physician with a request for an opinion. For most claimants, the IME conclusion report is adverse to the claimant, and the opinion of the primary care physician is favorable to the claimant. Therefore, there remains no consensus of medical opinion regarding your impairment and the extent of your disability. Your file goes back to the drawing board, so to speak, to the insurance company physician for a decision, which is what the disability insurer wanted in the first place. What is different is that your file now contains what appears to be a creditable effort on the part of the insurance company to obtain an "independent opinion" of your ability to do work. Is it really an independent medical opinion? No it isn't. Is it a fair and unbiased review? Not at all. Who makes the final decision as to the liability of your claim? The disability insurer.

 Nothing has changed with regard to your file except for the appearance of credibility, and the addition of yet another document supporting the agenda of the insurance company to deny your claim.

            Independent Medical Evaluations are not necessarily a bad thing in every case. The insured often pays for an IME and submits the result to the insurance company. If the disability insurer is interested in fulfilling its fiduciary responsibilities, the IME report should be considered in the liability decision. Unfortunately, most disability insurers consider only medical information IT solicits and pays for. When correctly used, the IME should be given equal weight with the recommendations of the primary care physician, and other information obtained from the claimant before making a final decision to pay or deny a claim for benefits. However, this is rarely done in the claims process. IME's can clarify complex restrictions and limitations and open the door for win-win situations with regard to return to work and disability. When a disability insurer places its financial interests above those of industry standards of care, and/or fails to consider the interests of the insured at least equal to its own, the disability industry as a whole suffers.