Do Insurance Companies and Medical Examiners Have Your Best Interests at Heart?

On this blog, we frequently discuss how after a serious, life-altering injury the victim of an accident feels that he or she may be able to work with the other insurance company. Unfortunately, the insurance company for the other driver or company that manufactured an inherently dangerous and defective product typically does not have your best interests in mind. Some individuals may even feel that he or she can turn to his own insurance company for fair treatment and adequate compensation.  

Unfortunately, on both counts, the company is unlikely to have the driver’s best interests in mind. Regardless of whether the insurance claims agent or adjuster is your own or the other party, it is essential to remember that they work for the insurance company and not for you. While it is certainly true that the most egregious examples of insurance company abuse occur when it’s the other party’s insurance, an array of abuses can occur in either case. Remember, the insurance agent works for the company and not for you. They have numerous career-based and other incentives to save their employer money by paying out as little as the client or claimant will accept. Thus, after suffering a catastrophic personal injury with potential lifelong effects, it is important to keep these factors in mind.

However, when a serious bodily injury occurs to an individual, including when a matter proceeds to the litigation stage, the insurance company is likely to require a medical evaluation of the injured party. This process is known as an independent medical examination (IMEs). Unfortunately, these IMEs are often extremely biased against the patient and are often used to minimize and deny either the existence of the injury or to minimize the effects and impacts caused.

What is an IME? Who’s Doctor Conducts the Examination?

As stated above an IME is an independent medical examination. However, the word independent of the term would make one think that both the injury victim and the insurer would work together to select a mutually acceptable, impartial third-party doctor. Unfortunately, this is not the case. The “independent” medical examiner is selected 100% by the insurance company. Furthermore, the insurance company pays the IME. Thus, even honest doctors face a subconscious economic bias that may affect their decision-making. After all, most employees and contractors are eager to make the party providing work and payment happy. Saving the employer or contracting party money may become a conscious or subconscious interest. It may not be stated explicitly, but most workers understand that a happy boss is more likely to use the party that achieved a good result again. Thus, examinations that create favorable results for the insurance company are likely to lead to more work while examinations that result in increased claims are likely to result in the employer finding a party who is willing and able to bring about the desired result.

Thus the insurance company has an incentive to minimize claims because the less the company pays out, the greater profits will be. The agent has an incentive to minimize claims to the benefit of his or her employer. Likewise, the medical examiner is also contracted by the insurance company and faces, at a minimum, the unspoken and underlying tension of working for one party in a disputed matter while simultaneously being expected to provide an unbiased report.

And this is the start of the problem with the process of IMEs – they are not independent. Unfortunately, many victims of catastrophic car accidents, defective products, and accidents accept the name at face value and do not realize what they have gotten involved with until it is too late and they have received the IME report. Then the report is used to cut-off coverage or to minimize their injuries during the ensuing trial. Alternatively, the report is used to deny or delay the claimant’s no-fault benefits. What this boils down to is severely injured people are unable to receive the medical care, supportive care, and rehabilitation they need to recover or treat their injuries. Unfortunately, this is merely the tip of the iceberg regarding IMEs, their use in claims and future proceedings, and the practices used during the exams.

Are Medical Exams Thorough? What About Second Opinions?

Unfortunately, we can’t even say this much about an IME. While medical examiners will claim to the contrary regarding their abilities, it is important to note that they are not your treating doctor. They do not have a treatment history with the patient during which they have seen the condition progress, regress, or remain unchanged. They do not see that the patient may have “good” days and “bad” days. Thus, it is entirely possible that the IME may see the patient on a “good” day and simply assume that this is how the patient is all the time and thus significant improvement has been made and will continue. Unfortunately, any person who has dealt with a traumatic brain injury (TBI), chronic injury, or neuropathic injury probably can already see the folly in this type of approach. These injuries can vary in severity and, furthermore, are highly subjective and open to significant interpretation, and lead to a failure to diagnose lawsuit.

Aside from these problems, the exams are typically anything but thorough. A specialist or other doctor may spend significant time with the patient and thoroughly assess the patient’s condition. After all, aside from the obligation and duty the doctor holds in regard to his or her patient, the treating doctor also likely has malpractice concerns in the back of his or her mind. Thus, examinations conducted by the treating doctor are typically thorough and comprehensive. Since the billing for the services proceeds through the insurance company, the tests conducted are recognized and accepted by the medical community and typically the insurer.

Unfortunately, IMEs are anything but thorough. The exams often consist of little more than a 10-15 minute visit with the consulting doctor. During this amount of time, how much can be accomplished? Furthermore, the doctors are often rushed, abrupt, and blunt with an already nervous patient. The nervous patient who does not realize the consulting doctor has certain economic incentives who is already intimidated by the process may defer to the doctor’s apparent judgement that “nothing is wrong”, that “the pain is actually caused by a preexisting condition”, and other statements without realizing just how damaging these admissions may be to their ability to receive benefits under their policy. Furthermore, the individual upon hearing that he or she is “improving” may take this as a positive development and alter their reports to the doctor.

In any case, it is essential for the injury victim to understand that the doctor is not performing an exam for treatment purposes. In many cases, the patient may not be asked anything more than “yes” or “no” questions and the only tests perform are subjective and of the type designed to mislead the patient into making a contradictory statement rather than to diagnose any particular condition. In other words, this is not an exam that will result in the examinee receiving medical advice. Furthermore, no treatment plan will be given as a result of the testing. Even if the patient asks the IME a question about his or her condition, it is unlikely that the medical examiner will provide any information that goes beyond boilerplate generalities.

Most Insurers Maintain “IME Physician Network” Lists

Another aspect of IMEs that most insurance claimants and litigants do not realize unless they are informed by a personal injury lawyer or other informed party is that many insurance companies maintain lists of approved IME doctors and physicians. The insurer may work exclusively from this list in which a doctor may perform hundreds of IMEs in a single year. These doctors appear on the lists because they are known by the insurer to play the role of devil’s advocate and typically disagree with the view that a patient is severely or permanently injured. Unfortunately, the fact that the same medical professionals end up providing these services in tens or hundreds of yearly IMEs further undermines the physician’s independence in this highly lucrative area.

What Should an Injury Victim Do When Facing an IME?

In future blog posts, we will continue to explore some of the practices of IMEs and the potential pitfalls that legitimately injured individuals face when engaging in this process. However, these blog posts are merely a starting point in understanding the goals and dangers of insurance company exams of this type. If you are facing a denial of PIP or other coverage, delay in coverage, or other aggressive insurance company tactics typically used in “deny, delay, and defend” strategies working with a personal injury lawyer may be necessary.  Lawyers are trained in advocacy and negotiation and can stand-up to the insurance company and fight these tactics. If the matter proceeds to trial, the lawyer will already be extremely familiar with the details of your accident and injury. To discuss how a personal injury lawyer can help you stand-up to difficult and complex insurance company tactics so that you can receive the compensation you need to pay for your medical bills and rehabilitation, call our experienced personal injury lawyers in Philadelphia at The Reiff Law Firm today at (215) 709-6940 or contact us online today.