Many U.S. workers who file for disability insurance benefits have straightforward claims.
Others claims are not as clear-cut, and that’s where independent medical evaluations are beneficial.
Occasionally, claimants and their agents question the necessity of an IME and, therefore, it is important to educate those involved in the claim management process about the purpose and value of an IME.
Managing a disability claim can be complex, and there are times when a claims analyst needs more information to provide an initial claim determination or help decide whether a claimant continues to be eligible for benefits.
An IME is an excellent tool for this purpose, in that it can help employers, insurance companies and third-party administrators, among others, gain an objective medical assessment of a claimant’s condition. An IME also can provide the claims analyst with the information needed to fully understand the claimant’s medical condition, level of impairment and prognosis. Whether an IME is appropriate depends upon the unique facts of the claim.
Of course, IMEs come at a financial cost. Therefore, understanding which particular areas of the claim require clarification, and why, is essential.
For example, an IME would not be the best choice if:
o There is a preponderance of evidence that supports (or does not support) the disability claim.
o Any further information obtained will not affect the claim’s handling.
o Prior IMEs have been conducted and no significant change in condition has been determined.
How Do IMEs Work?
IMEs are performed by board-certified physicians who are not involved in the care of the claimant. Their role is to provide impartial information for case management.
Given that the role of a physician in the physician-patient relationship tends to be–and should be–that of the patient advocate, an opinion from an independent physician brings a level of objectivity to the process.
A treating physician’s role may affect physicians’ ability to make an unbiased diagnosis and, in some cases, to recognize factors such as behavioral problems, symptom magnification and secondary gain issues related to any potential ongoing legal or financial matters. Furthermore, physicians are not always trained to assess functional capacity, and may fail to accurately assess a claimant’s true physical abilities relative to the diagnosis.
An IME can be used at any point in the life of a disability insurance claim. It can be particularly beneficial at the initial claim determination, or when a claimant has been collecting benefits for a period of time during which the definition used to determine eligibility for additional benefits changes from “own occupation” to “any occupation” (as typically stipulated in the plan summary description).
It is important to ensure that the claimant’s condition is stable or at maximum medical improvement before conducting an IME, particularly at the change in definition. Conducting an IME too soon limits the ability to evaluate the claimant’s full functional capacity.
It is also important to work with a physician whose specialty qualifies him/her to assess the claimant’s specific condition.
The typical IME requires a single visit with a physician. However, there are rare instances where an additional exam may be needed depending on case specifics. An exam is similar to most routine medical appointments, including a comprehensive review of the claimant’s history, medical records and any applicable tests or diagnostic studies.
o Determine the diagnosis
An IME can help to confirm and/or identify the diagnosis and ensure that all diagnostic avenues were pursued in the evaluation, so that the claims analyst has a comprehensive understanding of the condition.