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When you file a workers’ compensation claim after a work-related injury, you may be asked by your employer’s workers’ compensation insurance carrier to undergo an Independent Medical Examination (IME). An IME can have a significant impact on the outcome of your workers’ compensation claim. Therefore, before going in, it’s important to understand what an IME is, how to prepare for it, and how to conduct yourself during it.
What Is an IME?
The first step in the workers’ compensation application process is to notify your employer of the injury. If that is not possible due to the severity of your injuries, seek medical care immediately, but inform your employer of the injury within 30 days. Regardless of when you seek medical treatment, the treating doctor will compile a medical report and submit it to the New York State Workers’ Compensation Board. After you officially file a claim, your employer’s workers’ compensation insurance carrier may then request that you undergo an IME — even if you have already been seen and treated by your own doctor — to further assess your injuries. A doctor chosen by the insurance carrier will perform the exam.
Reasons Independent Medical Exams are Ordered
Workers’ compensation insurance companies typically order IMEs when there is a dispute as to a certain aspect of the claimant’s case. In common terms, an IME amounts to a “second opinion.” There are many reasons why a workers’ compensation insurance company might want to order an IME, but some of the most common involve the following questions:
- Whether the claimant’s injuries are related to the workplace accident
- Whether the claimant’s injury or condition is as serious as he or she claims it is
- Whether the claimant’s injuries prevent him or her from working
- Whether the claimant has reached maximum medical improvement
- Whether the claimant’s injuries are the result of a pre-existing condition
- What treatments the claimant needs or will need in the future
- Whether the treatments the claimant is receiving are appropriate
At the conclusion of your IME, the physician conducting your IME will issue a report to your workers’ compensation insurance company. While it is generally difficult to challenge the findings of an IME, there are limited circumstances under which you may do so. For example, if the IME doctor’s opinion is based on incorrect information from your medical history or another factual mistake, you may challenge the finding with supporting evidence. A Long Island IME attorney can help you to identify discrepancies between the IME report and the factual record.
Do You Have to Attend an IME?
Yes, workers’ compensation insurance companies can require you to undergo an IME if the insurance policy contains language requiring the claimant to submit to an exam. However, workers’ compensation claimants in New York have several rights regarding IMEs, including (1) the right to receive a videotape or other recording of the examination, (2) the right to be accompanied by an individual or individuals of their choosing, and (3) the right to be reimbursed for travel expenses to and from the examination site.
Should You Be Worried About an IME?
In most cases, insurance companies order IMEs because they disagree with the original treating physician’s findings, particularly if those findings indicate that you need extensive medical treatments and will not be able to work for a while. Many workers’ compensation applicants suspect that the doctor performing their IME will not be totally “independent.” This is not entirely untrue, as IMEs are a lucrative source of revenue for doctors, and many are keen to be re-hired by insurance companies after delivering favorable results. Insurance companies are also known for shopping around for doctors who frequently give them the results they want. While not all IME doctors are biased, understand that the doctor performing yours has an incentive to interpret the results in the light most favorable to the insurance company — not to you.
What to Expect at Your IME
An IME is different from a traditional medical examination. The doctor conducting the IME likely is an expert on workers’ compensation cases and work-related injuries and will be much more narrowly focused on determining the extent of your work injury and assessing whether and when you can return to work. Also, keep in mind that an IME does not give rise to a doctor-patient relationship or any type of confidentiality, so you can expect the doctor to relay everything you say back to the insurance company.
What Do Doctors Look For During IMEs?
The doctor conducting your IME will be looking at several factors during the exemption, such as:
Your Overall Appearance
The doctor will be paying attention to whether your overall appearance — including the clothes you are wearing — is consistent with the injuries you claim. For example, if you have an injured ankle, the doctor will be expecting you to show up in a cast, not high heels. If you have injured your arm, the doctor will expect you to be in a sling. If you have injured your leg, the doctor will expect you to be on crutches. IME doctors look for whether the people they are examining “look the part.”
Signs of Deception and Inconsistencies
IME doctors are experts at sniffing out deception and spotting inconsistencies that may harm your workers’ compensation claim. Did you have a limp when you walked in? Did you still have the same limp when walking to your car after the appointment? Did you grimace in pain at any point, and did it seem genuine? Do your current symptoms match what you told your own doctor previously, and are they the type of symptoms that would be expected for the condition you are alleging? Do any of your physical ailments directly affect your ability to be able to perform your job? Generally, the IME doctor will be looking for consistency and assessing whether you are being truthful about your injuries.
Your Medical Records
Expect your IME doctor to comb through your medical records, including test results, x-rays, CT scans, MRIs, prescription medications, and others, to determine whether there is any objective medical evidence of your condition. He or she will also be looking for mistakes in your initial medical evaluation or whether your own doctor made conclusions that were unsupported by the evidence. IME doctors — and the Social Security Administration (SSA), for that matter — put more stock in objective medical evidence than self-reported descriptions of symptoms. While self-reported symptoms can form a partial basis for a workers’ compensation claim, they will only help your case if they are consistent with objective medical evidence.
Your Responses to Physical Tests
An IME doctor will likely perform a series of tests on you to determine the nature, severity, and extent of your symptoms. He or she may also ask you to try to do certain tasks to see how well you perform. For example, if you claim that a back injury prevents you from working, the doctor may ask you to bend over and try to pick up a pen off the floor. If you are alleging a loss of eyesight, he or she may ask you to read letters off of a vision chart. The doctor will be assessing how well you perform or respond to these tests, as well as whether your pain or other symptoms of your condition are indeed severe enough to prevent you from working.
What to Do Before the Exam
There are several steps you can take to minimize the risk that an IME will sink your workers’ compensation claim. The most important thing to remember, as mentioned above, is that your IME doctor is not on your side; assume that he or she is skeptical of your claims and will be digging to find evidence that could undermine them. With that in mind, here’s how you should prepare for an IME:
- Figure out what the insurance company has told the IME doctor. Insurance companies usually communicate with IME doctors ahead of the examination in the form of a report that outlines your case and asks the doctor to examine certain aspects of your claims. Ask to receive a copy of this letter ahead of time to get a general idea of what the IME doctor will be checking.
- Get your facts straight. The IME doctor will ask you deep, probing questions about your accident and likely will want you to go into every little detail. Write down everything you remember in chronological order and study it ahead of the exam. Also, make sure that what you plan to tell the IME doctor is consistent with what you’ve said previously.
- Review your medical records. Familiarize yourself with your medical history. IME doctors will be looking for any previous injuries or pre-existing conditions that could be responsible for your present condition, so be prepared to explain how your current condition differs. Also, review the course of treatment you have undergone for your present injury and how well you responded to the treatments.
What to Do During the Exam
Your IME doctor will be meticulously watching your behavior and recording everything you say during the exam. Below are a few tips to make the best impression.
- Be polite. Your IME doctor may not be on your side, but you should still treat him or her with cordialness and respect. Hostility or rudeness cannot help your claim; it can only hurt it. Also, avoid anger and outbursts if you feel that the examination is not going as well as you had hoped.
What Not to Say During an IME
An IME can make or break your workers’ compensation case; as such, you should be very careful about what you say (and what you don’t say) during your exam. Remember that there is no expectation of privacy during an IME, meaning that anything you say during the IME can potentially be used against you by the workers’ compensation insurance company. Before undergoing your IME, keep the following in mind:
Don’t Lie
It goes without saying that you should never lie at any point during the workers’ compensation claims process. This applies to every detail about your case, including the extent of your injuries, the parties that were present to witness the accident, and the specific details about what happened, among others. But it is also possible to lie by omission, which occurs when you omit key details because you think they might harm your case. For example, you may be tempted to leave out that you suffer a pre-existing condition because you believe that your workers’ compensation insurance company will be more likely to deny your case. A better solution is to disclose the pre-existing condition and be prepared to explain how your new injury is different or more severe than that one. Also include all relevant details about the accident. Leaving out details that you consider to be embarrassing or harmful to your case can create inconsistencies between your statements to your employer and to your doctor, which can jeopardize your claim.
Don’t Exaggerate Your Symptoms
You might be tempted to exaggerate the extent of your pain during your IME, but doing so could have severe consequences for your workers’ compensation claim. Workers’ compensation doctors are experts at spotting exaggerated claims, disingenuous displays of pain, and complaints of pain that do not match those that would be expected for a person suffering your condition. Suspicion of lies and exaggeration can lead to a denial of your claim. Ideally, you need to thread the needle between maximizing the descriptions of your pain and going overboard with them. The best way to do that is to simply be honest with your examining doctor. If you are unsure of how you should prepare for your IME, a Long Island IME attorney can help you.
Don’t Speak Negatively About Your Employer
The workers’ compensation claims process can be stressful and leave a bad taste in many employees’ mouths about their employers. While it’s natural to harbor some animosity toward your employer — especially if your injury was caused due to your employer’s negligence or failure to create a safe workplace — you should refrain from speaking ill of your employer in an IME. You want your examining doctor to be on your side, and the best way to do that is to maintain a professional, courteous, and positive outlook at all times. Given that there is no doctor-patient confidentiality in IMEs, you should assume that everything you say will make it back to your workers’ compensation insurance provider and your employer.
Don’t Answer More Than Is Asked
Just as you should not leave out any key details, you should also avoid volunteering more information than necessary. For example, if the examiner asks you if your pain prevents you from bending down to lift heavy objects, do not say “yes, but I can still carry heavy objects as long as I don’t have to bend down.” Volunteering more information than is necessary increases the risk of inadvertently saying something that could harm your claim. If the examiner wants to probe a certain issue deeper, leave that decision to the examiner. Answering more than is asked can also increase the length of your iME.
Don’t Ask for a Diagnosis
You may be tempted to ask the doctor performing your IME for his or her opinion on your injury or condition, but you should refrain from doing so. The job of an IME physician is to evaluate the extent of your workplace injury and give his or her opinion only as to the disputed issues or questions raised by the workers’ compensation insurance company. He or she will be looking to answer a very specific question or set of questions, not to make a diagnosis. Your treating physician will be able to give you a complete diagnosis.
What to Do After the Exam
After the exam, write down everything you remember — what the doctor asked you, how you answered the questions, the tests he or she performed on you, how you did on the tests, etc. Once the doctor has fully assessed your condition, he or she will provide a report to the insurance company, of which you and your attorney should request a copy. If there are errors or conclusions not supported by evidence in the report, your attorney may be able to file objections or seek a deposition to interrogate the doctor who performed the IME. If you do not have an attorney, now would be an ideal time to hire one.
IMEs for Denied Medical Treatment Payments
Workers’ compensation benefits include the full cost of treatment for your work-related injury or condition, which encompasses all treatments that are reasonable and necessary for your recovery. However, even if your treating physician recommends a particular medical treatment, your workers’ compensation insurance company could nonetheless disagree and deny payment for that treatment. This generally occurs where the workers’ compensation insurance company argues that:
- The treatment is not reasonably necessary (i.e., there are cheaper and less invasive treatments that could be tried first)
- You have failed to follow your doctor’s treatment plan for prior treatments
- Your injury or condition was pre-existing and thus not work-related
- You have reached maximum medical improvement and further treatments are unnecessary
One strategy for overcoming denial of payment for medical treatment is to request an IME. While the workers’ compensation insurance company may disagree with your own doctor’s assessment of your treatment needs, it may consider an IME more persuasive. If the physician who examines you in your IME recommends the same or similar treatment as your treating physician, the workers’ compensation insurance company may approve the payment. If not, you likely will need to move on to the hearing and appeal stage of the workers’ compensation process, which an experienced Long Island IME attorney can handle for you.
