Can my disability claim be denied if my disability company never conducted an IME exam?

Can a disability carrier deny benefits to a claimant if they have never had an independent medical exam done on a particular claim?

They certainly can. Just because the insurance company fails to request an independent medical examination of an insured person, doesn’t mean they don’t have grounds on how they evaluate the claim, to terminate the claim. It’s usually done to further seek support for perhaps some findings that they already kind of felt are there. Many times these insurance companies have in-house physicians of their own that have certain findings based on the medical records and based on those findings they send out the claim to an independent medical doctor to look at what their own in-house physician is saying, what the claimant’s own physicians are saying, and as they say, generate an independent report.

But if the insurance company is going to render an opinion that a claimant is disabled how can they do that without ever examining a claimant?

Essentially what they will do is, they will go to their in-house doctors or some of their in-house nurses or sometimes send out the records that are already obtained by the claims people out to what they call independent peer review doctors. They just look at the notes, look at the records and make a determination on whether there are any restrictions or limitations.

So just by basically looking at papers, they can tell whether or not a person is able to work or not?

Yes, without ever examining the claimant they will essentially look at the paperwork and records and say that they can do their job.

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There are 4 comments

  • Tom, an IME can certainly be attacked as to validity if the doctor did not have all the records. As it relates to medical records for a disability insurance claim – it is the duty of the insured to provide “proof of loss” so it would ultimately be your duty to provide medical records in support of your disability. If your claim has been denied please feel free to contact our office to discuss the denial and your rights going forward.

    Stephen JessupFeb 4, 2018  #4

  • Would supposedly independent medical examiners opinions be considered invalid if they failed to review records on objective evidence of a disability o.e. X-rays, cat scans or MRI reports in their review?

    Does the claim fiduciary have to obtain your medical records when you make a claim or can it ignore the claim in hat regard and later claim a lack of medical record?

    Tom P.Feb 3, 2018  #3

  • DP,

    A disability carrier can “legally” deny your long term disability benefits at anytime. A lot of disability insurance companies will try to limit your benefits to two years if you have a mental nervous condition. If you have a physical condition that is disabling as well, then the disability insurance company must consider whether the physical condition prevents you from working. Disability insurance companies are notorious for ignoring your physical complaints and trying to make your claim mental nervous only. You can appeal and then sue the disability company for any wrongful denial of disability benefits. You need to make sure your doctors document that your physical conditions are disabling.

    Gregory DellFeb 9, 2012  #2

  • I’ve requested IME and Voc. rehab three times in the last two years that I have been collecting LTD. They keep saying that they will pass the request on to their in house examiners and see if it is an option, but nothing has happened. I’m currently coming up on the 2 year mark which, per the policy, ends coverage for mental/stress and they seem to be focusing more on the stress and anxiety that my PCP, and SSDI clearly states is caused by the accident that caused my injuries and the fact that I want to work but can’t. Can they legally terminate my benefits under this clause even though there are numerous doctors, specialists and surgeons verifying my physical injuries?

    DPFeb 6, 2012  #1

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