IME (Independent Medical Examiner / Examination) : 'Independent' from the Truth That Is!

As noted in an earlier post, the IME visit is required by the insurance company that is paying for your medical care.  If you fail to appear at the IME appointment they will refuse to pay your claim, but that only seems slightly better than what happens after you do show up.


I just received a Denial of Claim letter from Utica Insurance in the mail including the IME's detailed report with the "D&D Associates" fax tag at the top of each page--a quak doctor, the lawyer who hired the doctor, and the auto insurance carrier doing it's best to keep its hands clean while committing insurance fraud. There are several inaccuracies in the report; to name a few:

• ACCIDENT HISTORY:  It states that I said the ER x-ray revealed displacement.  I actually said--in writing--there was no displacement or broken bone.  I was specific about this because my injury is not to the bone structure and only the latter MRI could have shown the ACL tear and other damage.  I also wondered at the time of the IME why I--a non-expert in medicine of any kind--was being asked for diagnosis.  I have a degree from Harvard in Social Sciences, not medicine.
• EMPLOYMENT HISTORY: It says I state that I do not perform household chores, shopping, heavy lifting, kneeling, or carrying bags.  I currently can't perform these normal, every day actions, but normally I perform all of these functions--particularly because my wife has Rheumatoid Arthritis.  As respects kneeling, not only are we a Japanese household, but we are Buddhist, so kneeling is something I normally do on a daily basis, but obviously can't (been practicing Buddhism in a chair lately, and outstretched on the sofa before that).  We need a copy of the document I filled out at the IME's office to verify the context of the question and how I answered it--particularly because I wrote all over it.
• ORTHOPEDIC EXAMINATION: Lumbar--I told the IME I have constant pain in this area which makes it impossible to sit in a chair for long periods of time--like at work for example.  I recently had an MRI of this area to determine if I need surgery or some other kind of treatment as a result of being twisted when the car hit me.  It hurts as much right now as it did the week after I was hit.
• SUBMITTED RECORDS (Page 3): He notes the narrative report of the foot and ankle specialist but none of the other orthopedists who examined my knees.  Basically, they've chosen to review all medical information irrelevant to what I am being treated for and ignored the rest. 

This IME performed examinations on an assembly line.  His whole business seemed to be examinations like mine where the aim was to deny claims. 

At one point in the exam he said, "So the right knee isn't so bad." And I replied, "Not so bad?!  The MRI revealed a torn ACL and the surgeon says I need to have the same reconstructive surgery I just had on the left knee!"  But no note of this.  In fact, it seems my right knee is injured worse than my left knee was, but because the left knee was hit directly by the car it was in greater pain.

OK, so here's the game.  Do you stop going to treatment because you received this Denial of Claim Letter?  The answer is no.

Before this next part, please note the following Disclaimer:

EVERY CASE IS DIFFERENT AND EVERY JURISDICTION IS DIFFERENT.  THIS EXPLANATION IS NOT MEANT TO BE LEGAL ADVICE AND READERS ARE ADVISED TO SPEAK TO A LAWYER ABOUT THEIR OWN SITUATION.

OK, got it?  Good.  So here is the basic explanation why you shouldn't immediately go back to work untreated and injured for life (between the dotted lines):

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When you go to see a doctor after an accident involving a motor vehicle, the doctor asks you to sign a form called an "Assignment of Benefits".  This form allows the health care provider to bill the no fault carrier directly and to get paid directly.  It also assigns to the health care provider all the "rights and responsibilities" relating to the bill.  So, basically, the doctor assumes all of your rights to fight the insurance company to get paid.  This is very important because it means that once a doctor submits a bill to the no fault carrier, it is the doctor's sole responsibility to fight a denial.  The assignment further insulates you because, unless the denial is based upon something that you did wrong, such as failing to appear for an IME, or failing to give the doctor the no fault carrier's information within 45 days, the doctor is legally barred from trying to collect the bills from you. (You might want to confirm that you did sign an assignment for your surgeon).  The theory behind this is that the doctor is the best one to make a determination as to whether or not a particular treatment is related to the accident and once he has made that determination he should be willing to stand behind it.  

Now, many doctors do not realize that they cannot come after the patient for any denied bills but many do realize that and most busy medical practices employ lawyers who only do fault arbitrations. 

There is one thing to remember, however, about no fault arbitration:  If a doctor arbitrates or litigates a no fault denial and loses,  you would be barred from claiming that the treatment which was the subject of those bills was part of your case because a judge or a jury alread said it wasn't.  As a practical matter, though, it's not much of a problem because most of the arbitrations settle, most of the ones that don't settle are won by the doctors and, your case will likely be over before the arbitration is done.

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I will add my bit as an Insurance Guy that this really isn't dissimilar from what I said about Subrogation.  It means that you have waived your right to pursue compensation for your losses and given that right to someone else--a lawyer, doctor, or insurance company for instance.  Your monetary losses are therefore no longer your own, they belong to someone else.  The obligation you have to that other party is to assist in any way possible in their recovery of those losses and--very important--not to admit liability by saying things like "Oh wow, I'm sorry, it was at least partly my fault."

NEWS Flash: Sudden Lack of Physical Activity Can Make You Fat!

When I first came out of surgery and was taking strong pain killers every day I did lose some weight because I lost my appetite and nearly felt like throwing up all the time, and then there was the new sport of getting around on crutches.  But soon after, with all the laying around an inability to even ride a bike on a trainer for the first couple of months I gained no less than 5 kilograms (1 kg = 2.2 lbs) at a rate of about one kilogram per week.

What could I do about it?  I couldn't very well hop on the bike and burn it off, so I had to cut back on my calorie intake.  I even considered outright starving myself until I was down to my preferred weight.

It turns out this is not as tough as it seems.  The amount I would normally eat is based on my normal level of physical activity.  Since I was barely physically active at all, I simply didn't feel the need to eat as much.  In other words, I could eat the same foods, just less of them.  Where I would normally have two sandwiches, I've been having one.

But this is also an opportunity not to be missed.  I've been trying to lose some weight I gained after moving back to the States from Japan for the last several years but just couldn't do it.  Now I can not only cut down on the food I normally eat, but really improve my food choices here in the States (in Japan I never had to worry about it--it's all good).

It's still kind of upsetting to see my presently bloated body in the mirror, but I also see that I'm trimming down and will soon be at least back to normal.