Independent Medical Examinations
When you suffer a work-related injury, you can apply for workers’ compensation benefits covering lost earnings and medical expenses (after a construction accident, for example). Of course, to win your claim, you will need to prove that you actually suffered an injury. You will also need to demonstrate the seriousness of your injuries.
To prove your injury or illness, you will need a medical exam. If you select your own doctor to perform the medical exam, the Division of Workers’ Compensation (DWC) of the Texas Department of Insurance might question the objectivity of your doctor and demand that you submit to an Independent Medical Examination (IME). In an IME, a “neutral” third party will evaluate your condition before the DWC pays you any money.
Is an IME Mandatory?
You might voluntarily choose to take an IME to provide the DWC with a more objective (and therefore more persuasive) evaluation of your condition. If the DWC itself orders an IME, you must normally either submit to it or abandon your workers’ compensation claim.
You must also be careful to follow all orders and directions issued by the DWC and their doctors. Don’t give the DWC an excuse to deny your claim.
What Is Malingering?
Malingering is a form of workers’ compensation fraud that means faking or deliberately exaggerating an illness or injury to avoid work or to obtain fraudulent disability payments.
It is the fear of malingering that prompts many DWC demands for IMEs. If fraudulent claims are accepted, the workers’ compensation system will eventually run out of money for legitimate claims. Malingering can result in a denial of benefits, demands for reimbursement, and even criminal prosecution.
Why the DWC Might Refer You to an IME
The stated purpose of ordering an IME is to gain an objective view of the existence and severity of your injury. From your employer’s point of view, however, the purpose might be to have you declared fit to return to work as soon as possible.
If your IME doctor declares you can assume light duties, you must return to work with reduced benefits. If they declare that you have reached MMI (“maximum medical improvement”), you may need to pursue a settlement that closes out your claim entirely. The DWC is likely to refer you to an IME if:
- The insurance company disagrees with your doctor’s medical opinion concerning your condition;
- Your claim is expensive, or is expected to become so; or
- The insurance company is looking for an excuse to reduce your benefits or deny your claim completely.
In any case, an IME will likely (but not necessarily) lead to a neutral or unfavorable outcome for you, especially if you proceed without a lawyer.
What Happens at an IME?
At an IME, the doctor will be someone selected by the DWC, not by you. The doctor is not your friend, and they are not a neutral third party. Be careful what you say or do because the doctor is likely looking for a reason to deny or minimize your claim.
That doesn’t mean the doctor will commit fraud; they probably won’t. It just means their role is something like that of an opposing party.
The doctor will probably ask you the following questions, among others:
- How did your injury occur?
- Have you experienced a similar injury before?
- What kind of treatment have you undergone so far?
The doctor will probably conduct a physical examination. They might also test your range of motion in a particular arm or test certain occupational abilities. Don’t exaggerate or fake anything because that could prevent you from receiving compensation.
How Persuasive Is an IME?
An IME is persuasive medical evidence because a supposedly neutral third party administers it. Do not underestimate its influence on your claim. A good workers’ comp lawyer might be able to convince the DWC that your original medical evaluation was more accurate.
Can You Appeal an IME?
No, you can’t–an IME is final. What you can do, however, is to appeal the denial of a workers’ compensation claim. Your workers’ compensation lawyer may also come up with other options to handle a scenario like this. Don’t try to pursue an appeal on your own.
Think Outside the Box
If you can identify an at-fault party other than your employer who should bear liability for your injury (a construction site owner, for example), you might be able to file a personal injury claim against them. If you win, the damages you can claim from your pain and suffering might more than account for the effects of an adverse IME.
You Have the Right to an Attorney
Even though pursuing a workers’ comp claim does not involve an appearance in court, you still have the right to retain an attorney to help you at all stages of the claims process.
Take advantage of this right by seeking the services of an experienced workers’ compensation attorney, at least if your injury or illness is causing you substantial disability. Most workers’ compensation attorneys offer free initial consultations.