Disability Insurance Claim Advice
Look for the "Wow" Factors to Discover Problems With a Disability Exam
California Broker, February 2017
By Art Fries
For those of you not familiar with disability insurance claims, an I.M.E. is the abbreviation for the Independent Medical Examination. One of the tools that insurance company claim departments use to try to get a better picture of the claimant is to have them examined by a physician with an expertise in a particular area. This could involve an exam by an orthopedic physician or a psychiatrist or any one of a number of specialists who can offer an opinion on the claimant’s medical symptoms.
That examiner might be fair and objective or have a bias in favor of the insurance company or they may even have an agenda that goes well beyond that of the I.M.E. Following are three "war stories." Each one includes a "wow" factor.
My client, an orthopedic surgeon, had a pending claim for cervical issues. An I.M.E. was set up with an orthopedic surgeon hired by the insurance company. Upon entering the office for his scheduled appointment, my client noticed that all the employees were male and all were wearing jewelry on visible parts of their bodies (ears, tongues, etc.). I always tell my clients to observe the office atmosphere, and this was an interesting observation.
In the exam room, the physician proceeded to close the door and then put a latex glove on his right hand. My client then asked the doctor what he was planning to do and the response was, “I’m going to do a rectal exam.”
My client asked, “What does a rectal exam have to do with my cervical issues?”
“We do a rectal exam on everyone who comes into this office.”
A definite “wow” factor. At that point my client indicated that he wasn’t going to subject himself to this invasive type of exam. The examining doctor said, “That’s OK, it’s voluntary on your part.”
Since the request for a rectal exam did not seem very professional in this particular scenario, I had my client send a letter to the insurance company indicating as such, and that, of course, damaged the credibility of the examining doctor in challenging the denial of benefits.
In this claim my client suffered from major depression. An I.M.E. was scheduled with a psychiatrist who happened to be the president of his state psychiatric association. That sounded like a pretty good credential.
But I always recommend that my clients do an internet search on the examining doctor to see if we can find any "wow" factors. After some reading my client called me and said he found a "wow". He referred me to the doctor’s website. It was clear to me after reading the material on the site that this doctor performed a lot of Q.M.E’s – Qualified Medical Examinations – which are common in worker compensation cases and are forerunners to an I.M.E. From information shown on the website it appeared that the psychiatrist did not even have any personal patients. Here is the "wow": A statement on the website said the following: "If you are coming into my office for a Q.M.E. I know that you are a liar, so don't lie." After telling my client how to secure a copy of the I.M.E and having a copy sent to me, we were of the opinion it was a boilerplate report provided to the insurance company by the psychiatrist that was a piece of crapolla, and once we advised the insurance company of the stupid statement on the examiner’s website, his credibility was destroyed.
My client in this last case was an injured practicing oral surgeon, a DDS and also an MD. An I.M.E. was set up by the insurance company. A subsequent email to me by the client describes the exam:
"The doctor listened to all my complaints, but may not have heard what I said, since he seems to be a little scatter-brained. He kept asking his assistant what he needed and said 'She does everything, but I get the credit, and if she retires then I will too.' He did a perfunctory physical. He did not look at the MRIs or the radiographs that I brought with me and said he did not need these. He seemed to be intrigued by my degrees and education. I left the office but returned to get copies of the paperwork I had filled out and I heard him say from the back room (without knowing I was there), 'I never examined anyone who knows more than me'…and then laughed out loud."
The "wow" factor can certainly help you to challenge the results of an I.M.E or Q.M.E that became a justification for a denial of benefits.