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            In theory, IME's are intended to "clarify" very complex medical restrictions and limitations which in turn decide disability. Social Security requires them, but sparingly. Worker's Compensation uses IME's to determine a percentage of full-body disability in order to gauge disability.

            Claim denial decisions made by the disability insurer do not happen over night. Your claim for benefits is "risk managed," a term I refer to as "stacking the deck." The disability insurer refers your claim through a very complex internal review system whereby each medical and/or vocational resource provides a written document explaining all of the reasons why that resource believes you can work and are not disabled. Each in-house resource lends their certification credential-nurses are RN's, vocational specialists are CRC's (Certified Rehabilitation Counselors), and of course physicians are always "Board Certified" in their specialty.

            Most disability insurance providers maintain a master list of "IME Physician Network" participants. (Some companies outsource a network of physicians used to perform defense insurance exams.)  These IME physicians perform hundreds of medical evaluations each year for the insurance industry, and make doing so a large part of their practice. Their bias in favor of the insurance company is well known. The regular fee charged for performing these IME's range from $1,200 to $5,000 for detailed two day neuropsychiatric exams. If a physician is asked to give testimony at trial, the bill charged to the insurance company, doubles, or even triples. The "business" of performing several hundreds of insurance IME's proves to be very lucrative for the physician. You do the math. For some specialties, performing IME examinations can be more profitable than clinical services!

            The problem is, these insurance industry physicians are not "independent medical examiners" by any sense of definition, and can actually add to the controversy of medical impairment by drawing conclusions, writing reports, and providing testimony that is clearly biased in favor of the insurance company. In addition, after long periods of time, the IME physician becomes extremely knowledgeable of the disability lingo, and assumes the role of the disability claims specialist, or vocational consultant, and documents statements in his/her report about your occupation and how you do not meet the definition of disability in your policy. 

            An IME physician is limited in comments to his/her medical specialty. For example, an IME physician who does a write-up about  what a "Financial Planner" can and cannot do, has overstepped his medical specialty. The IME physician often becomes the "devil's advocate" by rendering opinions and conclusions outside of his or her own medical expertise. IME physicians may also assume the role of a disability claims investigator, paid by the insurance company, to provide documentation adverse to you and your claim.

            Therefore, it is important to remember IME physicians are not concerned with your medical well being, and themselves have a clearly defined agenda and strategy to assist the insurance company with what appears to be, credible, objective medical opinion contrary to that of your primary care physician. You are not their patient. They have no legal right to offer you opinions as to your future care.

            Their role is to attack the credibility of the insured by assuming every claim for benefits is a fraud that must be exposed. Therefore, it is assumed the claimant is dishonest. It is a great deal easier to attack your credibility, and the judgment of your physician(s) than it is to ascertain medical restrictions and limitations preventing you from returning to work.

            In doing so, the conclusion could be favorable to YOU and that would be adverse to the insurance company. Although the disability insurer is charged to decide matters decidedly in your favor, they often do not, and therefore breach their fiduciary responsibilities.

            IME physicians are provided with all the medical information you previously sent to your claims examiner, plus the copies of the in-house medical write-ups done by the insurance company physicians. Therefore, the IME physician already knows the "opinion" of the insurance company concerning your ability to work before you arrive for the evaluation. It seems reasonable to conclude the IME physician may have already formed an opinion concerning your impairment, especially when the insurance company also provides non-medical information such as the amount of your monthly benefit. The higher it is, the more persuaded the IME physician may be to document his/her medical conclusion in accordance with the insurance company's agenda of terminating your claim.

            Lately, disability insurers have required claims handlers to study and obtain industry credentials such as HIA (Health Insurance Associate) or other relevant disability claims titles. (ALHC) Documentation, written by well-credentialed specialists is added to your claim piece by piece, and is done to give the appearance of fairness and objectivity when in fact the claim is being prepared step-by-step for denial. Disability claims are very rarely denied in short, closed periods of time. It takes willful effort and a lot of work to legally document the reasons why everyone employed by the insurance company believes you are not impaired and entitled to benefits. It takes a long time to "stack the deck" (your file) in favor of denying you the benefits to which you are entitled.

            As previously mentioned, IME examinations are one of many "risk" activities used by the disability insurer to attack the credibility of you and your primary care providers. The internal decision to request an IME is not made by just one individual, but a series of people-nurses, doctors, managers, consultants and claims examiners. Everyone working on your claim knows the intended reason for the IME is to document a future denial, but the exam is positioned very differently with you since the company needs your cooperation. You are more likely to give it if you are under the impression the insurance company is requesting the evaluation to "award" benefits and not "deny" them.

            Recently, a major insurance company was fined $15 million dollars by a 47 state insurance commissioner investigative committee for abuses relating to the documentation and evaluation of IME's. (Among other issues.) There is no doubt but that disability insurers need to change the process and motivation for the examination.

            This write-up is intended to offer suggestions for managing a request from your disability insurer for an Independent Medical Evaluation. Although the insurance company may convince you it is in control of the process, the suggestions that follow will assist you in making sure the IME is as fair and objective as it can be, given the fact that your disability insurer is looking to create supportive documentation to deny your claim. It is probable if you are not prepared for the evaluation, your claim may be denied or seriously damaged. Although the following suggestions won't guarantee a continuation of your benefits, knowing the process is certainly an important step in protecting your rights.