How IMEs Can Strengthen Workers' Comp Claims

What you’ll find below:

• How IMEs Can Support Disputed Medical Issues in Litigation
• Questions an IME Can Help Address
• What Makes an IME Defensible

When a workers’ compensation claim reaches litigation, a party may need more than the existing medical record to support its position. Disputes over causation, maximum medical improvement (MMI), permanent impairment, and treatment necessity often require a medical opinion that addresses the issue directly. That’s where an independent medical examination, or IME, can become an important part of the claim.

Why an IME Matters in Litigation

An IME becomes particularly important when a claim involves a medical issue that could affect the outcome of litigation. If an insurer, employer, or claimant disagrees with a treating physician’s opinion, simply disputing it isn’t enough. There needs to be medical evidence supporting the alternative position.

An IME can provide that evidence. A workers’ compensation IME is a medical evaluation performed by a physician who hasn’t treated the claimant and is generally focused on the specific issue in dispute. Depending on the claim, that could mean determining:

• Was the injury work-related?
• Is treatment necessary?
• Has the claimant reached MMI?
• Is there permanent impairment?
• What work restrictions, if any, are medically supported?
• Is additional treatment likely to be needed in the future?

An IME is most useful when it addresses the specific medical question at issue and provides a well-supported opinion that can be considered alongside the existing medical evidence. The goal isn’t simply to get another medical opinion. It’s to develop medical evidence that supports the position being taken in the claim.

The specific rules around IMEs vary by state. Each jurisdiction may have different requirements for who can request an IME, how many exams are allowed, and whether the other side can request its own evaluation. In some states, a judge selects the examining physician rather than the insurer or employer.

Before requesting an IME, claims professionals should understand the applicable state rules. Those requirements can affect how the examination is conducted and how much weight the resulting opinion may carry later.

What Makes an IME Defensible

Having a different medical opinion doesn’t automatically mean a party will win the dispute. In many jurisdictions, an IME physician can be deposed and cross-examined. In some cases, that testimony becomes just as important as the written IME report.

An opinion based on an incomplete medical record or one that doesn’t hold up under questioning may carry little weight, even if it technically creates a dispute. That’s why getting an IME into the record is only the first step. The opinion also needs to be thorough, well-supported, and able to withstand scrutiny.

Timing matters, too. An IME requested early enough to schedule the examination, review the findings, and complete a deposition if needed gives a claims team more time to build its case. Waiting until a hearing is approaching can turn the IME into a rushed exercise rather than a useful piece of evidence.

Treating the IME as part of the evidence-building process, rather than simply another box to check, can help ensure the resulting opinion is prepared to withstand scrutiny.

How an IME Fits into the Bigger Picture

An IME becomes one part of the medical evidence considered during a litigated claim. The judge or arbitrator may weigh the IME physician’s opinion against the treating physician’s findings, diagnostic evidence, and other information in the record.

The IME physician’s role is to provide an independent medical perspective on the specific issues being disputed. That can give the parties and the court another medical basis for evaluating questions such as causation, treatment, MMI, or impairment.

It’s important to note that an IME does not automatically determine the outcome of a claim. Its value comes from providing a qualified, well-supported medical opinion that can be considered alongside the rest of the evidence.

Need an IME that can stand up to scrutiny? Connect with our experts today.

Sources:

• “Independent Medical Examinations in Workers’ Compensation Claims & Legal Implications.” Justia.
• Lennie J. Thompson v. Liberty Northwest Insurance Corp. Workers’ Compensation Court of the State of Montana, 2004 MTWCC 16.
• Professional Guide to Physician Participation. State of Connecticut Workers’ Compensation Commission.