If you have an on-the-job injury or occupational illness, you may run into disagreements with your employer’s insurance company about your medical condition or treatment.
In fact, medical disputes in workers' comp cases are common. The rules for dealing with these disputes may be different depending on where you live and the specific contested issue.
In most states, however, you may have to attend what’s usually called an independent medical examination (IME) with a physician other than the doctor who’s treating your injuries.
The results of an IME can have a big impact on the workers’ comp benefits you receive. And you must cooperate with an IME, or you could lose your right to collect those benefits. So it’s important to understand how the process works, what to expect during and after the exam, and how you can challenge the results.
Reasons for Independent Medical Exams
The insurance company may request an IME to address specific disputes, such as:
- your diagnosis
- whether your medical condition was caused by your work or something else (like an old injury or something you did outside of your job)
- whether treatment or medication that your doctor has prescribed is necessary and reasonable
- if you’re able to work and, if so, if you need changes to your normal job duties or hours; and
- whether the work injury or illness has left you with lasting physical or mental limitations and, if so, the level of your permanent disability.
The claims adjuster may send a letter to the examining physician that gives a summary of your case and outlines the issues to be addressed in the IME. You (or your lawyer) should ask to see this letter before you go to the exam, so that you can check for mistakes about the facts in your case and see whether the questions are appropriate.
Some states use a different process (often called “utilization review”) to resolve disagreements about medical treatment in workers’ comp cases. Generally, an outside physician will review your medical records and decide whether the recommended treatment is appropriate, without an in-person exam.
Who Chooses the Doctor for an Independent Medical Exam?
Although an IME is supposed to be independent and unbiased, that’s often not the case. The rules for selecting the examining physician vary from state to state, but the insurance company usually chooses the doctor when it has requested the exam. Unfortunately, these doctors often have a financial incentive to write reports favoring the insurance company’s position, because they want to keep getting referrals.
Some states have tried to address this problem by using randomly selected lists of qualified physicians for IMEs, or by having the workers’ comp judge name the examining doctor. A few states also allow insurance companies and lawyers for injured employees to agree on a particular examiner. When they do that, they generally must also agree to go along with that doctor’s opinion.
Depending on your state’s rules, you may also be able to request an IME and pick the examining physician. You might want to do this because you disagree with your own doctor’s opinion or a report written by the insurance company’s IME doctor.
What Happens During an Independent Medical Exam?
Typically, the IME doctor will begin by asking you a series of questions. The specific questions may depend on the issues to be addressed in the exam, but they may include inquiries about your medical history, the nature of your job, the circumstances of your workplace injury, your symptoms and treatment so far, and your ability to return to work.
In particular, you should anticipate questions about your health before your workplace injury. The doctor might be trying to see if you had a preexisting condition, unrelated to work, that caused your injuries. For example, the examiner may try to pin your back injury on a previous job, your recreational activities, or an old car accident.
During the entire interview, the doctor use different ways to assess your credibility and look for signs that you're exaggerating or not telling the truth. These methods may include:
- watching your facial expressions and body language to see if you seem like a credible, rational person
- checking your answers against accident reports and your medical records, and
- repeating the same question (maybe in different words) throughout the exam to see if your answers are consistent.
After the interview, the doctor will conduct a physical examination. The nature of your injury will determine the specifics of the exam. For example, the physician may manipulate parts of your body, ask you to perform certain tasks, or conduct other tests in order to:
- test your range of motion or strength
- observe whether your body’s physical response matches the symptoms you’ve described, or
- see if you give consistent responses about the level of your pain.
(Learn tips on how to prepare for and conduct yourself during an IME.)
How an Independent Medical Exam Affects Your Workers' Comp Case
The IME physician will write a report that includes:
- a summary of what the physician found during the exam
- any additional testing that might be necessary, and
- the doctor’s opinion about the disputed medical issues.
The insurance company will use the report when deciding what to pay on your claim. You (and your attorney) will also receive a copy of the report. If you disagree with the findings and are able to get a second IME, you or your lawyer can use the report from that exam during settlement negotiations with the insurance company. And if you can't reach a settlement, the workers' comp judge will decide which report is more accurate.
How to Prepare For an Independent Medical Examination
Here are a few steps to take before your IME that might help the exam go more smoothly:
- Find out what the insurance company has given the IME doctor and what its questions are. The insurance company will send the examining physician a copy of your medical records. The claims adjuster may also send the doctor a letter with a description of your injury or occupational illness, an outline of the medical care you’ve received, and a list of the disputed medical issues or questions in your case. Ask to see this letter. That way you can correct any mistakes and know what the IME doctor will be looking for.
- Review your case. Make sure you have a solid understanding of the timeline of events leading up to this point. You should know when and how your accident happened, or when you first began experiencing symptoms of a chronic occupational illness or repetitive stress injury, as well as the medical treatment you’ve received, how much time you took off work, your current physical limitations and symptoms, and what your treating doctor has recommended. If you had previous injuries or physical problems affecting the same part of your body as the current injury, try to recall when those problems were resolved. Go over accident reports, claim forms, medical records, any personal notes you took, and other documents that will help refresh your memory.
- Arrange to bring help. You may want to consider asking a family member or friend to come to the IME with you. Although helpers can’t interfere with the exam or answer questions for you, they can provide emotional support, take notes, and later act as witnesses if there’s a dispute about the fairness or impartiality of the examining doctor. Depending on the rules in your state, you might also be allowed to have your treating doctor present at the exam.
If you don’t already have a lawyer, this is a good time to consult with one. An experienced workers’ comp attorney can help you prepare for the IME, write an objection to the insurance company’s letter to the IME doctor, and anticipate questions that could trip you up. Your lawyer can also help you challenge the doctor’s report after the exam, if that becomes necessary.
How to Conduct Yourself During an IME
Plan to arrive for the IME early. If you're too late and miss it, you could risk losing your right to benefits. Be sure to bring any medical equipment or devices that you usually need for your medical condition. When you’re arriving or leaving the doctor’s office, be mindful of the fact that you might be watched or even followed.
Once you’re in the doctor’s office, be polite and respectful to the doctor and staff. While you’re waiting, you may be asked to fill out a questionnaire about your condition.
Sometimes, these questionnaires can be too broad and intrusive, asking questions that you’re not legally required to answer. For example, the questionnaire may ask for your entire medical history or about personal habits that have nothing to do with your injuries.
Your lawyer, if you have one, can give you advice before the IME on how to approach the questionnaire. But in general, a safe approach is to answer relevant questions about your injuries, medical treatment, and current limitations, but keep it brief. Ask for a copy of the questionnaire for your records.
Throughout the exam, keep a few rules in mind:
- Be truthful. Always tell the truth, and avoid the urge to exaggerate your symptoms or limitations. An examining physician who has been hired by the insurance company will be looking for any chance to diminish your credibility. If you’re honest, the doctor will have a hard time suggesting that you’re trying to milk your workers’ comp claim for all its worth.
- Be consistent. Remember that your answers to the doctor’s questions should match accident reports, medical reports, and any prior statements you’ve made. Also, be wary if the examiner asks you the same questions repeatedly. This is probably an attempt to catch you contradicting yourself. Remind the doctor that you’ve already answered the question or refer to the questionnaire you filled out.
- Remember the purpose of the IME. The doctor is there to assess your condition and give an opinion on the medical issues in dispute. The examiner is not your treating physician, so there is no doctor-patient confidentiality. Anything you say in the exam will be relayed to the insurance company. Don’t ask for advice, don’t volunteer information, and avoid social conversation.
- Watch out for questions about prior injuries. If you’ve had a previous injury to the same body part, be especially mindful when answering questions along these lines. The doctor may try to play up your old injury as the cause of your current injury rather than your workplace accident. Whenever possible, make a clear distinction between your old and current injuries. For example, if you hurt your back in a car accident ten years ago but fully recovered and didn't have any pain for eight years before your recent work accident, be sure to explain that.
- Be clear about your current limitations. If it’s one of the disputed issues that led to the IME request, the doctor will probably decide whether and to what extent you have permanent physical or mental limitations as a result of your work injury or illness. This “rating” or percentage of impairments could translate into the amount you receive for a permanent disability award. Because of this, it is important to tell the doctor about all of your current limitations. For example, if you have trouble with overhead reaching or standing for long periods of time, make that clear, even if the doctor doesn’t ask.
Above all, be calm, polite, and respectful. If you come off as defensive or agitated, it will only hurt your case. If you feel yourself getting worked up, ask to take a short bathroom break. If you don't understand a question or don't remember something, say so. Being truthful, reasonable, and credible will help your IME go as smoothly as possible.
Contact a Workers' Comp Lawyer
Because the IME report is such an important part of any workers’ comp case, it’s best to consult with a lawyer as soon as the insurance company has requested an exam. An experienced workers’ comp attorney can help you prepare for the exam and challenge an IME report that’s harmful to your case. For instance, your lawyer may:
- submit written objections, particularly when there are mistakes about the facts about your injury or medical record
- schedule a deposition with the examining physician to ask questions that could undermine the doctor’s findings or opinion, and
- help you find a good doctor to conduct another IME if that’s allowed in your state.
Learn how to choose the best workers’ comp lawyer for your case.