Why Do Insurance Companies Request a Medical Exam?

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Why Do Insurance Companies Request a Medical Exam?

In our second video in this series, Attorney Ben Schwartz explains why the insurance company will often request a medical exam for personal injury or workers’ compensation cases.

Hi, I’m Attorney Ben Schwartz,

Today we are doing our second video in the series on IME’s and DME’s. If you watched the first video you know that an IME is an independent medical exam and a DME is a defense medical exam, essentially they are the same thing. It is a medical exam with a doctor chosen and paid for by the insurance company in a personal injury case or a workers’ compensation case. The doctor examines you and gives an opinion to the insurance company as to the nature and extent of your injuries. The doctor determines whether you need more medical treatment, whether you need to continue out of work restrictions and continue receiving lost wages.

Today we are going to answer the question, “why is my insurance company requesting medical exams?” There are a lot of different reasons why people in personal injury cases and workers’ compensation cases get sent for medical exams. Let me give you a few examples of situations where this comes up so that you will know why you may be getting sent to this type of medical exam. Let’s say that we have an auto accident case and the driver in the auto accident sprains his neck and goes to the hospital to get an x-ray of his neck. It is not fractured but now he needs therapy. He goes to physical therapy, spends a month and physical therapy says his neck is healing but it is not all better. He goes to his doctor, the doctor says, “why don’t you go for another month of physical therapy?” Physical therapy is very expensive. The insurance company on the automobile is paying for physical therapy and they want to know, “do we have to keep paying for another month of this expensive physical therapy?” They may send the man injured in the auto accident to their doctor to find out the answer to this question. Their doctor may say yes he needs another month of physical therapy, or their doctor may say he is all better and does not need any further medical treatment. If that is the case, then the insurance company will say they are not paying for any more medical treatment.

Another scenario where an insurance company may obtain a medical exam. Let’s say that a person is in a store and there is a dangerous condition. Someone has spilled water all over the floor, the person slips and falls in the water. They fall and crack their head on the floor and gives themselves a massive concussion. They bring a lawsuit against the store for letting that dangerous condition exist. They are pursuing a lawsuit claim for personal injuries for medical expenses and for the cost of time out of work. In connection with that lawsuit, the store’s insurance company, instead of paying the claim defends it. The insurance company refers that plaintiff to their doctor to do an IME to evaluate the plaintiff, to evaluate this concussion case, to give a report to say that perhaps the concussion is as bad as it seems or to give a report saying no the person does not really have a concussion and there is really no injuries stemming from the accident or stemming from the store’s negligence. That would be a good way to defend that case if you are the store’s insurance company.

A third scenario where you would have a DME is, let’s say that we have someone who is working on the job. They break their arm in an accident on the job and go to the doctor. The doctor says you cannot return to work, you need to have surgery on your arm. The doctor puts in a rod and screws to fix the fracture and the doctor sends them to physical therapy. The doctor says you cannot return to work. Your left arm has got a fracture. It has a rod and screws in it and until it is fully healed I do not want you returning to work because I do not want you messing up my surgery. The workers’ compensation insurance company or the employer is paying not only for the medical care and treatment but also for paying for that worker’s lost wages. They do not want to keep paying for lost wages forever and so perhaps they will send that individual to a doctor for a defense medical exam to find out if that person truly cannot return to work. Or perhaps the doctor will say the person can return to work in a light-duty capacity and limit the job duties to one hand only, but get them back to work. In that scenario, the insurance company can try to cut off that person’s lost wage benefits if they do not return to work using one arm only.

These are some common scenarios we see where people are referred by insurance companies in personal injury cases and workers’ compensation cases to doctors of the insurance companies choosing on the payroll of the insurance company for purposes of independent medical exams or defense medical exams. I think that answers the question of why the insurance company would refer you to a doctor? It is because they want to either get someone who is favorable to them and who will give them testimony, to give an opinion as to the continued need for treatment, as to the nature and extent of the injuries, as to the continued need to continue paying lost wages. Those are the scenarios where we commonly see IME’s or DME’s taking place.

We are going to do more videos in this series on IME’s and DME’s and personal injury and workers’ compensation cases. Keep watching if you have questions about IME’s, DME’s or personal injury cases, in general, send me an email using the link below. If it is something pertaining to this topic I will be glad to do a follow-up video. Thanks for watching!

Be sure to watch our first video in this series, Independent Medical Examinations versus Defense Medical examinations, or IME vs DME in Personal Injury cases.

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