How to Challenge a Biased IME in Your Long-Term Disability Claim
Many employees opt into long-term disability insurance expecting protection if illness or injury keeps them from working. While these plans may seem fair in theory, the claims process can be a very different story. One common obstacle is a denial based on a so-called independent medical examination (IME) that favors the insurer’s position. The good news is that you have rights, and you can challenge a biased IME in your disability claim. Typically, you have multiple opportunities to appeal an unjust denial.
Attorney John Robert Peace at the Peace Law Firm has multiple decades of experience helping employees fight against unfair insurer tactics. John Peace can help review your benefits claim and work to build a strong appeal. You deserve support when dealing with a debilitating condition, and our legal team is here for you.
Disability Defined
Long-term disability insurance is designed to replace income when a serious medical condition prevents you from working. Whether you qualify depends on the definition of “disability” in your policy, which often falls into one of these categories:
- Own occupation disability. This means your condition renders you unable to fulfill the duties of your current occupation. This definition typically applies to the beginning stages of a claim.
- Any occupation disability. This means that you have a condition that renders you unable to perform the duties of any alternate occupation, given your experience and qualifications. This definition often applies after your policy’s “own occupation” disability period ends.
To evaluate whether you meet the policy’s definition of disability, the insurer may order an examination of your abilities under the terms of the plan.
Why an Independent Medical Exam?
Both insurers and employees have rights under South Carolina law and the federal Employee Retirement Income Security Act of 1974 (ERISA). Insurer rights include the right to send you for an independent examination of your condition.
While an IME examination is an “independent” examination, keep in mind that the insurer chooses the doctor and pays for the exam. So, the results of an exam may be partial to the insurer and give it the ammunition to deny your claim. You should be ready for this possibility and know what might happen during an exam before you go.
What Happens During an IME Examination?
An independent medical examination may include:
- A review of your medical records (often selected by the insurer);
- Physical or functional testing; and
- Questions about your symptoms, daily activities, and work duties.
The doctor may also ask about your job responsibilities and whether you believe you can continue working. Please remember that everything you say and do (even before you get to the examination room) may be included in the final report.
Potential Bias in Independent Medical Examinations
While IMEs are supposed to be objective, some claimants encounter what are commonly referred to as “IME doctor tricks”: tactics that may minimize symptoms or misrepresent functional limitations in order to support a denial. Here are some potentially biased actions to be aware of.
Watching You Outside of the Exam Room
Sometimes, your examination starts in the parking lot. An IME doctor’s staff might be watching you as soon as you enter their property or receptionist area to take note of how well you move or how “happy” you seem while waiting to see the doctor. And a doctor may use these notes to dismiss your symptoms while refusing to acknowledge that you aren’t performing taxing work duties while waiting.
Isolating Symptoms
An injury in one body part can cause symptoms in another. For example, a back injury might cause back pain and referred pain in your arms and hands. And if a doctor focuses only on back symptoms, they might argue that you can still perform your typing work while sitting in a comfortable chair. This would likely be an unfair picture of your abilities.
Not Asking Questions
A doctor might not ask detailed questions about your duties and how they affect your symptoms in order to argue that you can still work. Before you attend your examination, you may want to write a list of all your obligations and symptoms so that you don’t forget to mention them (even if the doctor doesn’t ask).
Not Reviewing Your Complete History
An IME doctor should have a comprehensive understanding of:
- Your abilities before you developed your disability, and
- Every time your symptoms have worsened or limited you.
If a doctor has incomplete records or ignores certain reports, their report might paint a biased picture.
How to Challenge a Biased IME in Your Disability Claim
South Carolina law and ERISA give you the right to appeal a benefit denial, and the appeal stage can be critical in getting the benefits you deserve.
Here are some key steps to a successful appeal.
Read the Denial Letter Carefully
The insurer must provide a written denial explanation. You want to identify every reason in the letter for denying your claim. You also need to follow the appeal procedures outlined in the letter and your policy.
Review the Full Claim File
You have the right to review the information the insurer used to make its decision, including the IME report. Reviewing this information can help you identify holes in the insurer’s arguments.
Submit a Timely Appeal
You typically have at least 180 days to appeal a denial through your insurer’s internal processes. Your appeal should respond to every stated reason for denial and include all supporting documentation, such as:
- Medical reports,
- Witness testimony, and
- Policy documents.
You might have the opportunity to submit subsequent internal appeals. And you might have to use every internal appeal opportunity before going to court.
Talk to Us
A biased independent medical exam does not have to be the final word. At the Peace Law Firm, our highly experienced and top-rated benefits attorney can help you hold a disability insurer accountable and fight to obtain the benefits you need. Call us or contact us online to schedule a consultation.
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