Do Insurance Companies Rely on Biased Doctors for Claims Denials?

Do Insurance Companies Rely on Biased Doctors for Claims Denials?

Recent studies reveal that insurance companies commonly use reports generated by biased physicians to determine the result of injury claims – a bad faith insurance tactic that can result in a case being minimized or denied altogether. It is common practice for insurance companies to use Independent Medical Examinations (IME) to help them determine whether they will pay an injury claim to victims who are injured in motor vehicle crashes, workers compensation cases, and other accidents. While this technique may seem like a good idea on the surface, a deeper look reveals the startling truth.

When Are IMEs Used in Injury Cases?

One of the most important parts of an injury case is the medical evidence that supports (or does not support) the claim. When there is strong medical proof that the injuries sustained caused severe, disabling or permanent damages, there is a good chance that the insurance claim will be successful. If there is contradicting information, inadequate testing or other reasons to possibly dispute the severity of an injury, however, it is common for a claims adjuster to demand that the victim undergo an IME. In a claims process, there are three common reasons that trigger a request for an IME.

  • There Are Issues at the Beginning of a Claim: In many cases, a claims examiner will demand an IME at the beginning of the claim process. This is especially true when medical information exists that does not match up with the injury claim. The adjuster may indicate that he or she suspects that the victim is claiming an inaccurate diagnosis, or that the severity of injuries and limitations are exaggerated or misstated.
  • When Preexisting Conditions Are Discovered: When pre-existing medical conditions exist that could potentially cause the symptoms included in the injury claim, an insurance company will typically request that an IME be performed. If a victim suffers from another condition that could be responsible for the pain or limitations included in the claim, for instance, the opinion of another medical expert may be sought.
  • If Symptoms Are Not Improving as Expected: Insurance companies often use specific guidelines to determine the expected duration of medical treatment and lost time from work for most conditions. If a victim appears to be “milking the clock”, so to speak, the insurance company might demand that an IME be conducted.

IMEs Rarely Work in a Victim’s Favor

Independent Medical Exams are usually performed by medical experts that are actually anything but independent. In most cases, the physicians who are chosen to perform these evaluations are hired over and over by third party vendors for various cases, and they are typically paid very handsomely for their services. The doctors involved are usually briefed by a representative of the insurance company about the case and a strong focus is placed on the possible problems surrounding the claim. When these medical experts reliably come up with medical reasons that minimize or contradict injury claims and their reports favor the interests of the insurance company, they have a better chance of being chosen for these types of services again. If their reports are not favorable to the insurance company, they will likely not be referred more cases by the company.

Recently, more than 500 IMEs conducted by physicians chosen by a popular nationwide insurance company were turned over for review, opening a window to the way insurance companies use doctors. An evaluation of the reports revealed just how often IME doctors gave opinions that enabled the insurance company to deny or minimize claims. While the details of the evaluation have not yet been released, an attorney involved in the case asserted that the results indicate that the insurance company has repeatedly hired experts that create reports that enable insurance companies to wrongfully deny benefits to victims throughout the nation.

When the Insurance Company Requests an Independent Medical Examination

IMEs are rarely beneficial to an injury claim. Fortunately, victims are not typically required to submit to them except under certain circumstances. For instance, if the insurance policy states that submitting to an IME is required, or the appropriate legal procedures to request an IME are followed when a case goes to court, then the completion of such an exam may be in order. When a victim must submit to an IME, there are certain steps that can be taken to ensure his or her rights and benefits are protected. Claimants should:

  • Record the exam whenever possible to make sure that an accurate account of the events that occur is available.
  • Bring a friend. If the claimant’s bad faith insurance attorney is not available to attend the exam, the individual should bring another witness.
  • Be honest and thorough. Claimants should try to remain as consistent as possible throughout the exam and cooperate to the best of their ability to avoid having their claim discredited.