Disability insurance companies are notorious for requesting Independent Medical Exams (IME or CME) in an effort to try to deny disability benefits. Our disability insurance lawyers have helped thousands of claimants to prepare for these obviously unfair and often biased examinations. Unfortunately disability claimants are required to attend an IME exam and cooperate while being examined. Let’s take a look at a recent ERISA disability denial lawsuit in which a claimant a neuropsychological IME exam but failed to cooperate with the examiner.
Claimant Denied Disability Benefits After 12 Years Due to Failure to Cooperate
A Federal Appellate Court recently upheld the termination of disability pension benefits under an ERISA governed plan for a claimant who had been on claim for 12 years due in part to her failure to cooperate during a Plan ordered Independent Medical Examination (IME). In finding that the Plan did not abuse its discretion in denying benefits, the Court noted that the Plan conditioned continued eligibility for disability benefits on “compliance with recommended treatment” and “cooperation during evaluations requested pursuant to the Plan.” During the course of the claim, one of the claimant’s treating doctors noted that she was no longer in compliance with recommended treatment, which in turn raised a red flag and prompted an evaluation of her claim by the Plan.
In evaluating the claimants continued eligibility for disability benefits, the Plan informed the claimant that she must attend an IME to include neuropsychological testing. Following initial refusal by the claimant, she finally underwent the testing. The results of the testing indicated that she put forth inadequate effort, exaggerated her symptoms, and possibly malingered. Based upon what was deemed her failure to put forth adequate effort and “cooperation during evaluations requested pursuant to the Plan” her benefits were denied. The claimant appealed the denial twice, filed a lawsuit and lost, and then appealed the initial court decision to the Appellate Court.
Appellate Court Agrees With Lower Court And Upholds Disability Denial
During appellate review, the Court noted that the claimant was granted the opportunity to submit additional documents to explain her test performance, and that the information provided on appeal failed to show she was incapable of participating in the IME. The Court, in rendering its decision, even points to the fact that the Claimant had been able to adequately perform the requested testing less than two years earlier.
The Court ultimately made the following findings:
- It was not unreasonable for the Plan to require attendance at two IME exams in an 18 month span;
- It was not unreasonable of the Plan to require her to attend the neuropsychological IME; and
- The claimant’s failure to comply with treatment and to cooperate during the IME evaluation were reasonable grounds for termination of benefits.
Lessons Learned From This Recent Disability Denial Lawsuit
This recent case serves as a reminder that it is extremely important that a claimant comply with all provisions of a Plan. We have previously discussed the importance of attending required Independent Medical Examinations, and that the failure to do so could result in the denial of benefits. This case takes this discussion and evaluation one step further by holding that attendance alone is not enough, that adequate effort and cooperation must be given during an IME. However, it must be noted that the ERISA governed Plan at issue in this case specifically stated “cooperation during evaluations requested pursuant to the Plan.” Each Plan (or Policy) can be written with different language, so it is important to know and understand your duties under your particular Plan. This case also serves as a reminder that disability benefits, be it from a disability pension plan or disability insurance policy, are not guaranteed benefits and that entitlement to benefits will be continually reviewed on a month to month basis. Lastly, this claimant could avoided this entire situation if she had complied with her treating physicians treatment plan and had supporting documentation from her treating physician.
For more information on Independent Medical Examinations please see “What should I expect when I attend an IME exam requested by my disability insurance company” and “Do I have to attend an IME requested by my disability insurance company?“. If your insurance company is requesting you submit to an IME or you have questions regarding your claim for benefits please contact Attorneys Dell and Schaefer for a free consultation.