Your Independent Medical Evaluation

Whenever you place your mental or physical impairment at issue with the expectation of receiving
disability compensation, the disability insurer (or other responsible party i.e. worker’s compensation)
has a right to have a physician of its own choice examine you. Although the procedural rules
governing IME’s vary among federal and state jurisdictions, several general requirements are
universal. Some disability policies have contractual provisions requiring you to submit to an IME, if
requested, others do not.

The disability insurer must give you reasonable notice of the time, place, and name of the IME
examiner as well as the scope of the evaluation. You have the right to be reimbursed for mileage
to and from the place of the evaluation, and the insurer must reimburse the examining physician
for the evaluation report. The IME physician is required to provide a copy of the report to you,
or, your attorney within a reasonable time after the examination.

In exchange, you are required to provide copies of all medical office treatment notes, lab
reports, consultations etc. from each physician who has examined or treated you for the
impairment you are now claiming. In addition, most disability companies will also ask you for a
signed authorization so that other information may be obtained before your IME date. I realize
this may seem as though your privacy is being invaded, but patient/doctor privilege with respect
to the condition causing you to stop working is generally considered to be waived at the time you
make application for disability compensation.

The IME physician may be subpoenaed to give testimony under oath during a deposition, and
may be cross-examined at trial if your claim is litigated at a later date. Therefore, it is extremely
important to be prepared for the IME and understand the objectives of the examiner.

A disability “Independent Medical Evaluation” is a physical examination by a medical doctor
chosen by your disability insurer for the purpose of providing credible written medical
documentation which can be used by the disability insurer at any time to support a termination of
benefits.

In theory, IME’s are intended to “clarify” very complex medical restrictions and limitations.
However, in actual practice, the independent medical evaluation is a “risk management” tool
paid for by the disability insurer which “rubber stamps” a future decision to deny your 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. 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.

The IME physician often becomes the “devil’s advocate” who renders opinions and conclusions
outside of his or her 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.

Their role is to attack the credibility of the insured by assuming every claim for benefits is a
fraud that must be exposed. Therefore, the claimant is dishonest. It is a great deal easier to attack
your credibility, and the judgment of your physician 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.

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.

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 periodsof 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.

This booklet 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 protecting your rights.

The IME Process—Preparing Yourself
1.
Most likely you will receive a call from your claims examiner asking you to submit to an
Independent Medical Evaluation. During this same call, the claims handler will conduct
what is referred to as “an in-depth phone interview.” The purpose of the phone
interrogation is to obtain facts and comments from you which may be used after the
evaluation to show you are inconsistent with your responses.
What you say to the claims handler and what you tell the IME doctor should be the same. For
example, if you tell the claims handler you can’t use your hands or carry heavy objects, don’t lift a
large bag and drive an RV the day of the IME.
Always use common sense. Remember, the disability insurer may have arranged a “tag” surveillance
the day before, the day of, and the day after your IME. Whatever you tell the claims examiner about
your physical capacity should be the same as what you tell the IME physician, and should also be the
same as any observed activity should the company surveil you just before the exam.
Keep in mind when speaking with the insurance company to answer only the questions asked, then
bequiet. Never volunteer or offer additional information other than what is asked.
2
Once you know the date and time of the evaluation, call your primary care physician and
make an appointment with him/her just after the IME. Inform your primary care
physician at that time that your disability insurer has asked you to submit to an IME. This
second examination serves two purposes: 1) it provides documentation of your physical
condition by your physician on the same day as the IME exam, and 2) sometimes the
IME physician may be a little rough and cause you to swell or have pain. These physical
symptoms will be documented by your physician as well. Tell your physician if you have
pain, swelling, or any other physical symptoms as a result of the IME. The
documentation of your own doctor may be extremely important when pointing out
inconsistent and unreasonable conclusions made by the IME physician.

3.
You should meet with your attorney, if you have one, in advance to go over all of your
prior medical records and history of your present illness. One way in which the IME
physician may draw suspicion to your claim is to “catch” you in inconsistencies when
you talk about your prior medical history. A simple lapse of memory by not mentioning a
particular doctor, or lab test you had in the past is sufficient for the IME doctor to
conclude you are trying to hide something and your claim is fraudulent. No prior
physician visit or treatment should be left out of your history, as you will certainly be
asked about it at the beginning of the exam. You should be prepared either by your
attorney, or by studying your own medical records, well in advance of your IME date.
Refresh yourself with the following information: chronological medical history; a
statement of the nature and extent of disability; the date you first stopped working and
why; how your disability has affected your activities of daily living (toileting,
transferring, meal preparation, dressing and undressing, preparation of meals etc.);
restrictions and limitations given by all treating physicians,; and a complete description
of your treatment plan discussed previously with your physician.
Only when you arethoroughly prepared for discussing your medical history, can you avoid the “traps”
ofgiving an inaccurate or inconsistent medical history.
Skilled IME physicians will literally“pounce” on every omitted detail no matter how insignificant it may
seem.

4.
Send a certified, return receipt requested notice to the disability insurer requesting a
written reply to the following questions:

1) What percentage of the IME physician’s practice is devoted to diagnosing and
treating patients who are totally disabled from the same condition you now
have?

2) How long has the IME physician been employed by the insurance
company as an IME physician and what percentage of his decision reports have
been favorable to the claimant?

3) Request a copy of the Curriculum Vitae of
the IME physician.

4) Request copies of any published articles the IME physician
has written on the topic of your particular diagnosis.

5) Ask for a written statement explaining the basis for selecting this particular IME physician over
others to conduct the exam. This question is especially important if you are being asked to travel a
long distance to attend the exam when other well qualified physicians are within your own
geographical area. Look up the IME physician on the Internet and verify his credentials.

6) Request copies of the IME report be forwarded to both you and your primary care
physician. Remember to send this letter, certified, return receipt requested. In the case
of mental or nervous conditions state in the letter it is permitted to send the report
directly to you. Some insurance companies send such reports to your psychiatrist or
counselor rather than to you.

5. Request a continuance of the date (if appropriate) to allow you and your primary care
physician sufficient time to examine the credentials of the designated IME physician.

6. Never attend an independent medical evaluation alone. On the day of the exam, do not
engage in any substantial activity. Remain ever cognizant of the fact the insurance
company may have requested surveillance. Leave your house accompanied by someone
who can assist you during the exam, ask questions for you, and/or take notes of
procedures during the exam. If you are required to wear braces, wear them to the exam. If
you use a cane, bring it with you, and use it. Bring a camera with you and take a picture
of any swollen body part at the IME doctor’s office. For example, one person attended
an IME with a swollen hand, so she lifted up the hand next to the IME doctor’s certificate
on the wall, and took a picture. Later, the IME doctor wrote in his report that “there was
no swelling”, but the claimant’s picture said it all. Ask your companion to take accurate
notes and to observe how the IME physician treats you during the examination. Take
someone with you who is fairly assertive and who would not have a problem asking for a
break if you become tired, or need something to drink. Your companion is there to be
protective of your personal needs during the exam, and document what took place.

7. IME physicians use certain exams to trick you. One such test is referred to as Waddell’s
signs, used by IME physicians to identify psychological factors in patients claiming back
problems from trauma, chronic pain and fibromyalgia. So-called “false positives” on
these indicators are often at the root of adverse decisions documented by the IME
physician. The IME physician will perform a hands-on examination for each test, looking
for you to say “it hurts” when in fact it is impossible, given nerve or sensory distribution
for it to really cause pain. In other words, the IME physician “tricks you” into saying it
hurts when it really shouldn’t, given the injury or diagnosis you have. I’m going to try
and explain these Waddell signs in layman’s language so that you will understand them.
Tenderness-- the doctor will lightly touch or pinch your skin over a wide area beyond the
normal distribution of the sensory nerves. If you say these light touches are sensitive and tender,
superficially, the IME physician will suspect exaggeration. If you say you have pain when
deeply touched over a wide area beyond the area of an injury or joint, the doctor will suspect
exaggeration. Usually pain is only evident in the localized area of the injury. If you have
fibromyalgia and say you have pain “everywhere”, the doctor will suspect your reactions.
Simulation Tests-- If the doctor presses down on your head while you are standing (axial
loading), and you report low back pain, the doctor will say you are exaggerating. If the doctor
rotates your shoulders and pelvis at the same time while standing, and you are complaining of
low back pain, the doctor will say you are exaggerating.


Distraction Tests-- On occasion when the IME physician finds something wrong, he/she may
distract you, performing another test of the same area without telling you why. If you have a
negative reaction, or don’t give a full effort, the doctor will suspect exaggeration. An example of
this is to ask the patient to raise one leg against resistance while lying down. If your opposite leg
does not press down, for leverage, then the doctors suspects you are not giving full effort for the
purpose of exaggeration. Sometimes, the IME physicians will just walk away from you
supposedly to write something down in your chart, then quickly ask you a question. If you “turn
your head” in his direction when you told him you couldn’t do that because of pain, the doctor
will suspect all of your complaints. In most instances, the doctor has already examined you for
movement in that area, causing you to believe the exam was completed.

Regional Disturbances-- If you complain of excessive weakness, such as the giving way of
muscles within a particular group, the doctor will say you are exaggerating. Likewise, if you
claim numbness, tingling or pain over an area outside of the distribution where the nerves from
the spine lead down the leg into the toes, the doctor may suspect exaggeration. This is especially
true for fibromyalgia and chronic fatigue claim.

Overreaction-- If you cringe, grimace or otherwise show unnatural responses to sensory, motor
or reflex tests (all of the above), the doctor may suspect exaggeration.

8. Remember the IME physician is not examining you to give you medical advice. He/she
will not discuss treatment options with you, nor will he recommend appropriate treatment
for your impairment. An IME physician will generally not give you an opportunity to
explain what is really disabling you, and will ask only questions requiring a “yes” or “no”
answer. It is very human and natural, once you are committed to an IME exam, to want to
be believed, and acknowledge the doctor examining you is acting in your best interests.

However, once you thoroughly understand the IME physician’s role is to represent the
insurance company and not you, then you can present yourself appropriately during the
exam.
Technically, you are patient with a medical problem and you may feel the need to
ask the IME physician medical questions about your impairment. It is unlikely the IME
physician will tell you anything substantial as an answer.
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American Contractors in Iraq
Your Independent Medical Evaluation


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