Insurance Medical Exams and Workers’ Compensation

by Karl Voigt

When you have been injured at work, you and your treating physician make the important decisions. Both of you weigh treatment options and decide the best course of care. However, the workers’ compensation insurance company has a statutory right to get opinions from a third-party doctor in what they call an “independent medical examination” (IME). Because they are geared toward the interest of insurers, we often refer to these examinations as “insurance medical examinations”. Regardless of semantics, IMEs are a fact of life when you’ve been injured at work.

You and your doctor make decisions not only about your continued care, but also whether and when you can return to work and whether you have any physical limitations. While you remain in charge, the insurer has the right to seek an opinion separate from your treating doctor’s. This right stems from the Pennsylvania Workers’ Compensation Act (Act), which gives the carrier the right to essentially two IMEs a year.

These exams can significantly effect your workers’ compensation benefits.

The injured worker gets no say in which doctor conducts the examination. Rather, the IME doctor is chosen by the insurance company. And, frankly, these doctors are chosen because they reliably render opinions favorable to the insurance companies. As a matter of fact, IME doctors and their employing agencies often advertise directly to insurance companies, implying that their opinions will be favorable to the employer. One should never assume that the IME doctor is impartial. These doctors can make a significant income conducting IMEs and testifying against the injured worker later in the case.

First of all, not only do insurers have a statutory right to these examinations, they also have the right to attempt to stop your benefits if you fail or refuse to attend without justification. They can file a petition to compel your attendance at an exam. If granted and then you fail to attend the IME without good cause, the insurance company can actually attempt to stop your benefits until they reschedule a new exam and you attend.

Before you actually go to the exam, there are several things you should do. Be prepared to explain to the doctor exactly how your injury occurred. It may also be helpful to generate a timeline of your injury, establishing important dates like the injury, the first time you sought medical treatment, and any surgery dates. Make a list of the medications you’re taking to treat the injury.

When you attend an IME, the examining doctor has likely already received a packet of your medical records. With this packet, supplied by the insurance company, the doctor is often given a list of questions to answer. Namely, IME doctors are often asked to give an opinion on:

  • your diagnosis;
  • your prognosis;
  • whether your condition was caused at work;
  • whether your symptoms are related to the work injury;
  • whether your treatment to date has been reasonable and necessary;
  • what future medical treatment might be warranted;
  • whether your condition necessitates physical limitations;
  • whether you can return to work, either to your regular job or to modified duty;
  • whether you are fully recovered from your injury.

You are usually asked to bring along some form of identification. This is fine; it simply verifies that you are who you say you are. Sometimes, you are also asked to bring copies of any medical records or diagnostic studies that you have. You are absolutely not obligated to do this. You are by no means required to work for the insurance company; let them obtain those records if they find them important.

At first, the doctor will likely sit down with you and discuss the history of your claim. You should, of course, remain friendly but keep your answers to the point. While the doctor has been chosen by the insurance company, and while you may not have a good relationship with that company, the doctor should not be treated with contempt. Naturally, you should answer all of the questions honestly. as the doctor will likely already have your medical records. If you have a condition that pre-dated your injury, you should be candid about any other previous injuries, such as car accidents or work injuries. Keep in mind that the IME doctor has not established a doctor-patient relationship so anything that you say during the exam can be disclosed to the insurance company.

After the history portion of the examination, the doctor will conduct a physical exam. You are welcome to have a person of your choosing present during that examination to act as a witness. The doctor will likely conduct an orthopedic exam, which consists of strength, nerve, and range of motion testing.

Some doctors will conduct what is known as Waddell’s testing determine if there is a “non-organic” cause of your symptoms. The doctor is testing for exaggeration of symptoms. Doctors will look for inappropriate tenderness, diffuse, non-specific pain and overreaction. Sometimes, the doctor will conduct the same test a second time in a different position or with distraction. This is why it is important to be able to describe your symptoms very specifically. For example, if you have a back injury with leg symptoms, point out exactly where the symptoms are rather than simply saying “the whole leg”.

You should make a note as to the start and stop time of the exam sometimes, these exams are far shorter than those conducted by you’re treating physicians. If the examination only lasts just a few minutes, this might be brought up to the judge in the event your case is contested.

The doctor may actually observe you before and after the actual examination. Some doctors are known to watch you walk back to the parking lot afterwards to look for discrepancies.

After the IME, the doctor will write a report to the insurance company with his or her opinions answers to the questions posed. Sometimes, it takes weeks for the doctor to generate these reports, but you should obtain a copy of the report for your review. This is important because the doctors report could have a significant impact on your case. You should look for any factual mistakes or misstatements made by the doctor.

As was pointed out in the beginning of this article, you and your doctor are in charge of your medical care. The IME doctor generally does not have a final say in the course of your treatment. However, this examining doctor can still have a substantial effect on your case. If the doctor feels that you are fully recovered from your work injury, the insurance company will likely file a petition to terminate your benefits. If the doctor opines that you can go back to work at modified duties, your employer may ask you to come back to work accordingly. If your doctor disagrees that you can go back to work, the carrier will likely file a petition to reduce your benefits. During the litigation, the judge will likely hear deposition testimony from the IME physician as well as you’re treating physician. Wow you will always have the opportunity to challenge the IME doctor’s conclusions during litigation, there are things that you can do to avoid that litigation in the first place.

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