Today's Independent Medical Examiner is a Chiropractor

I have to go to the Independent Medical Examiner today. This one is a chiropractor. Basically, this is where no matter how injured you may be, the doctor is paid to say you are fine so the insurer can deny your claim. You could lose a leg and the IME would say you walked normally and required no further treatment.

I notice that they always have these examinations here in New York City in the most difficult to get to areas, and when you get there the waiting area is designed for discomfort, especially for the disabled.

The last IME appointment I went to, I had to wait about three hours and my spine was killing me. While there, I met someone who had been sent to an IME four times in a row and each time, after waiting for hours, they told him that they were done for the day and would have to reschedule him. I told him that legally they couldn't do that--as it was clearly unreasonable. The strategy was obviously that this person is very seriously injured, that there's no denying it, but if you keep requiring him to go to these appointments eventually he will miss one and then they can not only cut off his claim but refuse to pay any outstanding charges for treatment he has already received.

Lovely business, insurance.

No Fault And Doctor's Appointments: Some Basics You Should Know

If you were hit by a car in a No Fault state the first thing you need to know is that you can, and should go to any provider of care that accepts No Fault.  In New York this includes orthopedists, chiropractors, and acupuncturists.  You do not need prior approval, a referral, or have to choose from a list of pre-approved doctors as you would with an HMO or Workers Comp.  You do not need to contact the insurance company--in fact you should never speak to them directly unless your lawyer says you have to.

This is important not only so that you can get the proper care as soon as possible, but because it also supports your case against the driver's insurer and possibly the driver if you cannot receive an acceptable settlement from the insurer.  Remember, the auto insurer has claims people whose job is to reduce the amount of money they need to pay for your injuries.  The insurer would really love it if you didn't go to the doctor, they had their Independent Medical Examiner look at you, and then they could cut you off from receiving any medical care AND reduce the amount of liability money you would have received otherwise.

So in my case for instance, I was told at the Emergency Room the day I was hit that I should go to my regular doctor a week later for a follow-up.  Instead, I went straight to the orthopedist.  I went to the front desk and simply asked, "Do you take No Fault Insurance?"  They said yes, and I made an appointment.  If I had gone to my regular, general physician he probably would not have realized how badly injured I was, or referred me surgeons--and even if he did, for lack of a specialty his diagnosis would not have carried as much weight.

If that doesn't convince you, consider this.  When the insurer sent me to an Independent Medical Examiner, they sent me to an orthopedic surgeon; he was a quack who just denies claims all day, but he was a surgeon.  If the insurer feels they need a surgeon to deny your claim or cut you off from care, then certainly you need a surgeon on your side.  And it's paid for by No Fault, so you really have no reason not to see a surgeon.

The other main thing you need to know is that you can go to as many doctors as you like, but you can't go to two of them in the same day.  This includes Physical Therapy.  So in my case I can't go to a chiropractor or go to a follow-up with the surgeon and go to Physical Therapy on the same day.  So if you are receiving care from multiple sources, make sure to schedule them out.

Also don't let a lapse of time go between getting care and simply resting.  If you're not receiving treatment for a time, this indicates to the insurers--including Disability or Workers Comp--that you no longer need care.  As hard as it is to keep going, as much as you would love to take a month off from getting electrocuted, stabbed with needles, going to Physical Therapy, and getting your bones manipulated, you can't stop until you are 100% and ready to go back to your normal life.

Long Term Disability Application, Getting Ready for the Second Knee Surgery, and How I'm Doing in General

My next surgery, on the right knee, is scheduled for April 18, 2011.  I received a letter from the No Fault insurer requiring that I appear for an IME (Independent Medical Exam) to re-examine my condition on April 20.  Insert your own punch line here.

Financially I'm basically not bad off, but nervous of course because my Short Term Disability coverage will end on June 3 and I am currently submitting a claim for my Long Term Disability coverage through MetLife for any period thereafter that I continue to be disabled.

Submitting a claim for Short Term Disability and getting it extended is fairly easy.  So long as I am genuinely disabled my attending physician / surgeon will certify it and that's about all there is to it.

With my Long Term Disability there is a lot of work to do, but it hasn't been too bad so far.  MetLife sent me an initial package which consisted of a Personal Statement, a Physician's Statement, and a job profile from my manager at work.  Then they do a phone interview.  At this point it's been verified that I am injured and what my basic losses are in terms of income.

Then another package arrives, and this is where the real work begins.  There is another personal profile basically asking the insured to describe their own disability and limitations.  I am also required to show my work history for the past fifteen years and to apply for Social Security Disability.  If I am turned down for Social Security Disability, I am required to appeal.  Any money received from Social Security Disability, the insurance of the driver who hit me, or any other source providing for lost income will reduce the amount I receive from MetLife--so that my total compensation during my period of disability does not exceed my insured loss (which is 66.66% of my salary).  Additionally, I must provide a pharmacy record to basically prove that my disability is not the result of a pre-existing condition.  This process is meant to both confirm any income I may be receiving, and verify that my disability is the result of the particular incident which I claim caused it.

This is an important point about insurance in general.  The sole purpose of insurance is to return the insured to the state or condition they were in prior to the loss.  My bicycle for instance, which I discussed in an earlier post, had a loss paid equal to the cost of replacing the bicycle with a current, similar model--less depreciation of my old bicycle (which I object to, but them's the breaks); insurance doesn't pay for you to be in significantly better circumstances or with a superior replacement for your losses. Of course, being compensated for losses isn't necessarily a matter of money either.  An insurance company may choose to repair or replace something that is damaged rather than write a check.  The bottom line is, the compensation provided by an insurer for a loss should never be expected to exceed the value of the loss.

Having a loss is never like hitting the jackpot.  Your goal in dealing with the insurance after an accident is to be compensated for your losses as well as for any personal injury--such as pain and suffering or a significant change in circumstances such as the loss of ability to live, work, and even love as you would have had the accident never happened.

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."