You are receiving long-term disability benefits, and a letter arrives telling you to attend an Independent Medical Examination. The insurance company calls it independent. But it chose the doctor, it is paying the doctor, and the doctor’s report could be used to end your benefits.
An IME is not an ordinary doctor’s appointment. Here is what happens, what the doctor is really looking for, and five mistakes to avoid.
Why the insurer is sending you to an IME
Most LTD policies let the insurance company require medical exams during its claim review. Common reasons:
- the insurer thinks your condition may have improved,
- it questions the restrictions your treating doctors have given,
- your policy is about to switch from own occupation to any occupation, or
- it wants an opinion on whether objective findings support your symptoms.
An IME does not mean the insurer has already decided to cut you off. But take it seriously.
Is the doctor really independent?
The doctor is usually hired by the insurer or by a company that arranges these exams. Some physicians do insurance exams regularly. The IME doctor reviews records the insurer supplied, may see you only once, and may not understand how your symptoms rise and fall over time.
Being paid by the insurer does not automatically make a doctor biased or an exam unfair. But a doctor who spends 30 minutes with you may reach different conclusions from a specialist who has treated you for years, and that difference matters when the reports conflict.
What happens at the exam
Before: you may fill out questionnaires about your history, medications, symptoms, and daily activities. The doctor may review your records and imaging. You may be observed from the moment you arrive: walking in, sitting in the waiting room.
During: the doctor asks about your symptoms, treatment, daily activities, and past work. Depending on your condition, the doctor may test range of motion, strength, reflexes, gait, balance, coordination, sensation, memory, concentration, or mood. You may be asked to do movements that hurt.
After: the doctor writes a report for the insurer covering diagnoses, findings, functional restrictions, and often whether you can work.
Keep this in mind: the IME doctor may agree you have degenerative disc disease, fibromyalgia, or multiple sclerosis and still conclude you can do sedentary work. The diagnosis is often not what is in dispute. The question is whether you can sustain full-time work.
Five mistakes to avoid
1. Exaggerating
Do not say you cannot do something you sometimes can. Instead of “I can’t sit at all,” say: “I can usually sit for about 20 minutes before my back pain gets bad enough that I have to stand up or change positions.” Explain how often symptoms occur and how long they last.
2. Minimizing
Many people tell doctors they are “fine” out of habit or politeness. Don’t. Describe your bad days as well as your better ones, and what happens after you try something: “I can go grocery shopping, but afterward I usually have to lie down for an hour.”
3. Pushing past your limits
You do not have to prove you can do something you cannot safely do. If a movement causes pain, say so. If you cannot finish a test, explain why. But do not refuse reasonable parts of the exam without explanation. If something poses a real medical risk, say so and ask the examiner to note it.
4. Giving one-word answers about daily activities
When the doctor asks whether you drive, cook, shop, or clean, “yes” is not an accurate answer. Explain how long, how often, whether you need help, and what happens afterward. “I can make a simple meal, but I can’t stand long enough to cook dinner.”
5. Not documenting what happened
As soon as you leave, write down:
- when the exam started and ended,
- which tests the doctor did,
- the important questions and your answers,
- any test you could not finish, and why, and
- whether your symptoms got worse afterward.
These notes can be powerful if the report later misstates what happened.
Assume you may be watched
Some insurers use surveillance, including on the way to and from an IME. If you tell the doctor you cannot lift more than five pounds and an investigator films you carrying a 30-pound bag, the insurer will use that against you. A short video does not show pain, fatigue, or the price you pay afterward, and it does not prove you can work full time. But accuracy is your best protection. More: Can they cut me off because I drive, shop, or travel?
The IME is often one piece of a bigger case
The insurer may combine the IME report with surveillance, social media, records reviews, and a vocational assessment. A report that says you can sit six hours, stand two, and lift ten pounds often becomes the starting point for a vocational report listing sedentary jobs. More: How insurers use vocational experts.
If the IME doctor says you can work
The insurer may terminate your benefits based on the report, even if your treating doctors disagree. That does not end your claim.
- Request a copy of the IME report and your claim file.
- Ask your treating doctor to review it and point out errors, omissions, and unsupported conclusions.
- Compare the report with your own notes from the exam.
- If ERISA governs your plan, appeal within the deadline (at least 180 days). The insurer must give you any new evidence or reasoning it relies on during the appeal and a chance to respond, and the appeal record may be all a court will later consider.
Should you refuse to go?
No. Most policies require you to cooperate with reasonable exams, and refusing can be grounds to suspend or end benefits. If there is a real problem, raise it in writing before the appointment: a medical concern about a test, travel your condition makes difficult (ask about accommodations), or an examiner whose specialty does not match your condition.
Three things to remember
This is not an ordinary doctor’s visit. Be accurate and specific, without exaggerating or minimizing. And write down what happened as soon as it is over.
CTA: Got an IME notice from your LTD insurer? Call 770-351-0801 or request a free case evaluation before the appointment.
Related: Why your approved claim is being reviewed · 5 reasons the vocational report may be wrong · Why your doctor must describe limitations