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Episode 4 Independent medical exams requested by disability insurance companies can be dangerous



Disability insurance companies will often rely on either an Independent Medical Exam (IME) or an External Medical File review without examination in order to deny a long term disability claim. I never consider a an IME exam to be independent because you are required pursuant to the terms of your disability policy to appear at the exam and the allegedly independent exam is being paid for by the insurance company.

You should not think that your claim will be automatically be denied because an IME exam has been requested; however you must be prepared to adequately handle your IME Exam and all of the event both before and after the IME exam.

Unlike an IME exam in which a disability claimant is actually examined by a doctor, the insurance companies will often hire outside doctors to review your file and renders opinions about your physical abilities without ever examining the claimant. This process is known as external medical file review without examination.

In this episode disability insurance attorneys Gregory Dell, Stephen Jessup and Cesar Gavidia of Attorneys Dell & Schaefer discuss IME exams, the biases of many disability insurance companies that request these exams, and the “whore” doctors that regularly find that claimants are not disabled. In an effort to further educate disability claimants about IME exams and External File Reviews we will answer the following questions:

  1. Do I have to attend an IME exam requested by my disability insurance company?
  2. Why is my disability insurance company requesting an IME exam?
  3. Will my disability insurance company give me a copy of the IME report?
  4. Can my disability claim be denied if my disability company never conducted an IME exam?
  5. Are independent medical examiners hired by a disability insurance company truly independent?
  6. Are the outside companies hired by disability insurance companies to locate IME doctors independent?
  7. What can I do to protect myself during an IME exam requested by my disability insurance company?

If you had an experience with a disability insurance or an IME doctor, please post a comment so that the thousands of people that visit our website each month can learn from your experiences. The sharing of information can help stop the unreasonable claims handling practices of many disability insurance companies.

Please note: Disability insurance attorney Gregory Michael Dell created Disability Insurance Law TV in order to educate long term disability claimants about common issues related to long term disability insurance claims. New episodes are filmed on regular basis. Our disability videos are for informational purposes only and they are not legal advice.

There are 20 opinions so far. Add your comment below.

T. L. Smith:

I recently had to go have an IME exam done for Aetna disability which was required by them, that I go to their doctor, right when my long term disability policy was changing from my own occupation to any occupation. They refused to let me have a licensed RN nurse of my choice in the room for the examination and they also refused to let me video tape or record the exam. After a 30 minute exam, the IME doctor put in his file that I could do full time sedantary work.

Interestingly, I have had 3 specialists including two pain management doctors and a neurologist state that I was only capable of working no more than 10 hours a week of sedantary work. When I called Aetna to get an update, as I only had one month left before a decision had to be made, my anylist told me that they found I was capable of working full time sedantary work. When I asked how they can justify their doctor who is paid for by them, contradict 3 specialists and my primary care doctor, who had just done a new update the month before, I was told that medical conditions can heal.

I was told they sent information to my own doctor to dispute and if she didn’t dispute it, that my disability would be terminated May 31st 2011.

When I went to see my doctor on May 3rd 2011, she told me that Aetna sent her video tape that was taken of me without my knowledge or permission, which I hear is pretty common, however it is illegal for them to send video to a third party which then makes it used for public and or commercial use, without my written consent. Of course the video was edited to show me in a bad light and in favour of the insurance company. My doctor, stood her ground and said there was nothing in the video that indicates anything about me being able to work full time sedantary work. Once the video goes public to any third party, it falls under the privacy rights of an individual. The insurance companies, know it is illegal but they continue to do this practice to intimidate doctors and try to get them to change their evaluations and also to intimidate the claimant into dropping their case.

Attorney Greg Dell:

T.L., your experience with the IME exam requested by Aetna is the same protocol that we have seen with other Aetna claimants around the country. I have discussed Aetna’s IME tactics in other articles on this site. You should request copies of the IME report be sent to your treating physician and then have your treating physician send back a written response. It is important that your physician writes a very detailed response that takes into consideration your restrictions and limitations. If you need assistance with an Aetna Appeal, contact us for a free consultation.

Suzie:

Hi, I have Cigna LTD group insurance and right after I was approved 11/2015 I was in a bad auto accident 12/2015 I was very fortunate to only have minor injuries but oh boy did it exasperate all my chronic pain including fibromyalgia with high chance of PTSD that has caused so much miserable Pain, depression/anxiety and even worse brain function. It’s all been very slowly getting better. I told Cigna early on about the wreck and that it just exasperated pain. She asked if I received any money which I haven’t because I was already in pain and suffering and at fault driver just had $25,000 PIP with multiple cars/people involved. It turned out the accident also caused dislocated discs in joints of both jaws with fluid in left one, but I had TMJ prior so, I was hoping it would calm down some but I still have to eat soft foods, hurts to talk sometimes and they locked a few times and also tortures my neck problems and tension headaches.

Cigna has requested an IME and I’m afraid to call too much attention to the wreck and both my PM doctor and I feel this has probably caused permanent disability or at least wasted a year of possible rehabilitation and maybe another year before I’m even back to the way I was when I went out on disability.

1. Have you known there to be any limitations/restrictions on continuing to pay a claimant having this type of personal injuries while receiving benefits?

2. I’m terrified of this IME. The PTSD and high pain levels has ruined communication skills most of the time and memory is extremely poor (I sound much better when able to edit and take a very long time, like now) I’m not fit to handle a verbal examination. What can I do?

Thank you so much for your time

Attorney Stephen Jessup:

Suzie, it is not uncommon for disability to result from an accident. In a situation like yours if there is an open/or resolved personal injury claim Cigna may have the right under the policy to reduce your benefit by the amount received from any settlement. This would be largely based on the language in your policy. Your policy almost certainly creates a duty to attend an IME. Your failure to do so could result in your claim being denied. If you have additional questions please feel free to contact our office to discuss your claim further.

Micah A.:

I’m due for an independent review of my medical claim from CIGNA insurance after paying them my over payment of 48.000 dollars. I’ve had three spinal surgeries and still left with severe pain and headaches.

Victor Pena:

Micah, Cigna typically sends their claimants to independent medical evaluations before terminating the claim. If you would like to discuss your claim before your evaluation please contact our office to speak with an attorney.

Julue:

I am set for a IME on Dec 7 th 2018 through my long term disability insurance Met Life. I had Right knee surgery done in January 2017 which resulted in the surgeon doing someone else’s surgery on me resulting in terrible knee pain and a second opinion which resulted in a total knee replacement… My pain level is so out of control that my blood pressure is running 195/110 which after pain meds did not control the pain my dr put me on blood pressure medicatiion as the fear is a stroke or heart attack due to the pain causing my blood pressure to be so high… My life has change tremendously as my days are so painful I really do not do anything but elevate and ice my knee … rotating sitting and standing as my pain is so terrible I cannot sit or stand long periods…

Can you give me some suggestions on how to handle this independent orthopedic doctor that met life is sending me to see. My LTD has been approved until July 2019 but I know they are trying to stop paying my claim… My fear is I can not work as my pain is so bad they will stop my pmts and I will have no income.

Attorney Jay Symonds:

Julue, there are a number of steps you can take with respect to the IME to protect yourself. I suggest you contact our office and speak with one of the attorneys to address any questions you have regarding your specific situation.

Maria:

My LTD claim with Cigna is currently awaiting an appeal decision. I received benefits for 5+ years due to various serious disabling conditions. Over that 5 year period, Cigna denied my claim on 2 occasions, but overturned it on appeal each time. This most recent time, however, when my claim was up for review, Cigna again denied it. When I received my denial letter, it included not only my medical information, but the medical information of a different claimant. Clearly, this was an error on Cigna’s part, and although they acknowledged including another claimant’s medical information, they assured me that it did not affect the outcome of their review, as all of my medical information was included and it would have resulted in a denial, anyway. My claim has now been in the appeal stage for 3+ months.

Cigna is continuously delaying their decision during this appeals process and justifying the delay by ‘stopping and starting’ the clock on the 90 day deadline to render a decision, due to my submitting additional medical information. I was hospitalized during the appeals process and diagnosed with a very serious brain disease, so naturally, I submitted that medical information. Although I have various disabling conditions (severe RA, chronic soft tissue calcification, osteoarthritis, lumbar spine herniated discs with impingement, multiple lesions on my ovaries, for which upcoming surgery is scheduled, and the most recent diagnosis of central nervous system vasculitis (inflammation of the blood vessels of the brain), Cigna only did a rheumatology peer review. Per my most recent contact with my appeals specialist, she stated that at this point, as my rheumatologist has spoken to their rheumatologist and opined that I am totally disabled, evidenced by office notes, clinical exams (ultrasounds, x-rays and MRi’s), their rheumatologist disagrees and that the ‘tiebreaker’ would be my attending an IME.

I of course refused, after Cigna admitted that the IME doctor is indeed financially compensated by Cigna. They also stated that the ‘problem’ with my appeal is that I should have requested that, because I have various disabling conditions, my appeal be reviewed by a doctor of occupational medicine. How was I to know that I needed to request how Cigna conduct their review? Am I indeed obligated to attend an IME? Does Cigna’s error in initially denying my claim with another claimant’s medical information included in my file have any impact now on my appeal? And finally, if I do agree to attend an IME, am I able to record it or have a 3rd party accompany me to the exam? I would appreciate any guidance you can provide. Thank you!

Attorney Alex Palamara:

Maria, most policies might in fact require that you attend the IME. The only way I would be able to answer your question is by reviewing the policy governing your claim. I don’t believe another claimant’s medical records inclusion in your claim file will have an impact unless Cigna or their reviewing physician reviewed it and used such to justify their opinion of your claim. Regarding recording, you should request being allow to record it and have a 3rd party present. Call us to speak regarding your claim.

Mark:

I first went on Disability as a HS school teacher in 2014. My district had a disability plan which I participated. I was a class 3 Insured “All active, contracted Teachers of the Employer regularly working a minimum of 17.5 hours per week” I was approved by CIGNA and started receiving monthly payments. They sent me a letter that indicated the policy required me to apply for SSN disability which I did and was approved. Then in December 2016, I was informed on the phone by the claims manager that because my disability involved mental illness. I appealed this decision, but they never responded. I appealed again providing all my medical records including my physical ailments with my lower back injury I had suffered years before, and a bone on bone right knee that needed to be replaced like I had already done on my left knee several years before.

I contacted by phone and they said the matter was closed. I then spoke with someone from social security regarding my claim, and they told me to first request all the files, internal memo’s, letters, medical records that CIGNA had on file. Then contact CIGNA via registered mail an appeal or their appeal denial or I would see Legal Counsel. I shortly received a letter from CIGNA my appeal of the appeal to deny was being evaluated. Then I received a letter indicating for CIGNA indicating they have approved my appeal to appeal and they would respond in 30 days. After 30 days I received another letter saying they needed 45 days plus an additional 45 days. I rejected this. Then I receive a letter that CIGNA wants all my current medical records and treatment notes and I must agree to an independent medical evaluation. I was then contacted by ECN in Florida indicating they would set up this exam in the next 30 days.

They set up an appointment for Saturday, February 23, 2019. I had the same testing in 2016. I have been in email contact regularly with this doctor providing any additional information he required. He has completed his work and sent back to ECN. I requested a copy of the testing and results from ECN and they have refused saying only CIGNA can release these records. I faxed a formal request to the appeals manager for CIGNA requesting a reply back via Fax ASAP. Does anyone know about this ECN company and can they be trusted in coming to an impartial decision?

Attorney Jay Symonds:

Mark, there is a lot of information here and many fact specific questions. I suggest you contact our office and speak with one of the attorneys to address the specific questions you have regarding your situation.

Kristine:

I’m on LTD for chronic migraine with aura (per neurologist) which has caused mild cognitive impairment (per neuropsych exam). I’m a legal secretary and have to function mentally at a high level. I went off work for treatment, tried to go back, went off again and when I tried to go back with restrictions HR nicely warned me that because I was out of FMLA I could have no restrictions. I could be terminated for poor performance or calling in sick with no sick leave saved up. Now York Risk has set me up for an IME. With a medical doctor. I can see an independent neuropsychologist, or a neurologist. I’m afraid this doctor is going to ask me a few screening questions and deem me well enough to do a job that he doesn’t know the complexities of. What are my options if that happens?

Attorney Stephen Jessup:

Kristine, if your disability claim is denied you would have the ability to file any applicable appeals available to you. Please feel free to contact our office to discuss your claim/situation in greater detail.

Daphne:

I am dealing with the insurance company, Sedgwick and in April I was found fully favorable for my SSD for both me and my now adult son. I paid them 70,000 in back pay plus my adult son was required to give his full entitlement of 22,0000. My Dr sent in the last medical update in April asking for permenant disability as we discussed at that appointment. I actually watched him fill out the forms. Now that my Dr is requesting permenant disability, they won’t approve me longer than 2 months (which I’ve been dealing with for over 4 years, my Dr filling out new forms every 2 to 3 months). On top of that now I was informed they will sending me to an IME Dr for further evaluation.

My Dr is very thorough and does so much for me, office notes every 2 to 3 months plus filling new forms out, but this insurance company. Sedgwick has been so harrassing. From day 1, now they got their money… now they want yo get rid of me. Trust me, I’d love to work. I loved my job. Please advise.

Attorney Cesar Gavidia:

Daphne, unfortunately, you must continue to comply with the proof of loss requirements of your group disability policy. Sedgwick likely will not recognize your doctors opinion that you are “permanently disabled”. You may request that Sedgwick reduce the frequency of its request for updates; however, it is within Sedgwick’s discretion to grant your request or refuse it and continue to request for update every 2-3 months from you and your doctor. If your LTD claim is denied you may contact our office and ask to speak with a disability insurance attorney regarding your options.

Faith:

I have an IME exam next week. My husband is driving me there, and I would like him to be with me throughout the exam. Am I within my rights to have him present?

Attorney Cesar Gavidia:

Faith, you may make the request to your disability insurer that the examiner allow for your husband to be present during the examination. However, you do not have a right under ERISA to require that your husband or a third party be present during your examination and the insurer or its examiner may deny your request. You would still be required and expected to attend. However, if your claim is governed under state law you may have a right under your state’s law regulating insurance to have a third party present. You may contact our office and request a consultation with a disability insurance attorney if you have further questions.

Nate:

I recently got a letter from the State Disability In California saying I need to see an independent medical examiner. I had ankle surgery in my right ankle in January and have visited my orthopedic surgeon 4 times post surgery to see my progress post operation. He has stated I cannot return to work yet until my foot is bending at a 45 degree angle forward and backwards. The SDI now has made me schedule an appointment with an independent medical examiner to see if I can return to work.

I am afraid this examiner will decide I have to return to work even though my ankle is in pain and numb from the surgery. When I decide to drive anywhere my ankle experiences fatigue and my foot begins to numb. I have read reviews of this medical examiner and the results I have found have me very pessimistic about his report to the SDI. I would like to return to work and resume normal activities; however my orthopedic surgeon has informed me recover may take a year to do be able to do so.

Attorney Jay Symonds:

Nate, you can try to request a new IME examiner or request that you be allowed to bring a third party (spouse, friend, family member) to record – video and audio – the examination.

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