Challenging the Insurance Company’s Chosen Medical Examiner: Your Rights and Options

When you have submitted an Alberta personal injury claim, whether from a motor vehicle accident (MVA) or due to a long-term disability (LTD) claim, insurers will often send you to a doctor or other medical examiner who can evaluate you and report on your disability, injuries, and treatments. At Preszler Injury Lawyers, we know it can be intimidating to navigate the insurance claims process, and the prospect of being denied your benefits can have a drastic impact on your mental and physical health.

In this blog, we will outline the process for insurers’ independent medical examinations (IMEs) as well as your rights and options when dealing with medical examiners. It is important for you to be aware of your rights and options because the results of IMEs are usually a major factor in whether your claim is approved.

Who Is a “Chosen Medical Examiner”?

Your insurance company may order you to attend an IME. This is meant to be an outside, impartial assessment of your current medical condition, as opposed to one performed by your own doctor or an insurer’s internal medical advisor.

When sending you to an IME, the insurance company is supposed to find a doctor who is independent and unbiased, so they can ensure that the doctor’s reporting is fair and accurate to your condition. If the insurance is sending you to a medical examiner, it is often because they believe you have reached, or soon will reach, the limit of treatments needed, or that you are no longer as disabled as you claim to be.

Doctors are bound by professional rules to conduct IMEs fairly and accurately. In the worst cases, violating these rules could have serious consequences for the doctor.

However, bias could still be a concern since the insurance company is the one selecting the medical examiner and paying the fees. The doctor (or other healthcare professional) that your insurer chooses may have an incentive to return a report or result in line with the insurer’s interests, at least if the examiner wants to continue having a positive relationship with the insurer.

Ideally, this should not be an issue if the doctor remains unbiased and has the necessary qualifications to give a medical opinion on your conditions. The reality, however, is that sometimes you or your lawyer may not think a particular medical examiner is appropriate. What can you do in these situations?

When Can You Dispute the Insurer’s Chosen Medical Specialist?

Sometimes, the insurance company chooses the wrong specialist. An example is if you have largely psychological injuries and the insurer sends you to a family doctor, who is typically unqualified to give a psychological diagnosis. Other times, you might look and see that the doctor you have been assigned has concerning reviews online.

The specific requirements and procedures for an insurance claim will be different depending on the insurance company and on the specific contractual wording in your insurance policy.

For example, in Alberta MVA claims, and according to the standard policy of auto insurance, your own insurance company is obligated to pay for your medically necessary treatments within 2 years through your Section B accident benefits (AB) claim. In this situation, they have the right to request that you attend an IME. Failing to attend can often result in the insurer denying your AB claim altogether.

You may be able to request a different doctor or a different date for an insurer’s IME, but failing to provide adequate notice of these requests for changes could also result in them denying your AB claim. Our Alberta personal injury lawyers can help you to understand what your policy covers.

Requesting a Second Opinion or Independent Medical Assessment

If you received a report with unfavourable or incorrect information, you could request a second opinion about your medical examination, often referred to as a rebuttal IME, to determine if the initial IME’s opinions were fair. A rebuttal IME is typically performed by a doctor in a similar specialization to the original IME doctor, such as a physiatrist (who specializes in physical therapy and pain management) or an orthopedic surgeon. The rebuttal IME responds to the specific findings in the first IME. The other option would be to get an entirely separate IME, which may or may not use the same type of specialist as your first IME.

Knowing what type of specialist doctor to see for your injuries can be crucial in strengthening your case and ensuring your AB or LTD claim is not improperly turned down.

Our personal injury law firm understands that navigating the accident benefits process can be complex and intimidating. We have experience connecting clients with the appropriate medical experts to see.

We can explain the benefits and drawbacks of your available choices considering your personal circumstances. For example, submitting an internal appeal is likelier to succeed if the problem is simply a missing document that you have at home. If your AB claim is unfairly denied, we can also bring a claim against the insurance company directly for the value of your AB claim.

Negotiating With the Insurer for a Neutral Examiner

An important aspect of any injury claim is advocacy, whether through your lawyer or on your own behalf. You need to advocate with your doctors to ensure you receive adequate care and with the insurance companies to ensure you are not improperly denied your injury or benefits claims.

We always support our clients in trying to advocate with their doctors for appropriate treatments. Sometimes, you also need to take action to ensure you receive an IME from a proper neutral examiner. Usually, there are internal escalation and appeal processes within insurance companies that allow you to request different doctors or request changes to the details of the IME.

Processes are different among each insurance company. These processes are supposed to be clear and straightforward. Unfortunately, the insurance company is motivated to delay and deny claims to increase their profits, leading to a frustrating experience for the average person dealing with these types of claims.

We can help lay out the options available under your specific circumstances at a free initial consultation.

Using Legal Counsel to Protect Your Rights Against Bias

One of the most difficult aspects of representing yourself in a personal injury claim, is that you are often not aware of your rights or the insurance company’s obligations to you. There is no simple process or guidelines provided to you and often there is an imbalance in power and understanding between you and the insurance company. As businesses, insurers have an incentive to reduce claims approved and increase their profits.

This is why it is important to have a zealous advocate in your corner who is familiar with the claim processes and can negotiate with the insurance companies on your behalf. We at Preszler Injury Lawyers work hard to ensure our client’s interests are protected and to ensure they receive proper medical examinations from neutral examiners.

If you need assistance with a personal injury claim or dealing with your insurer to ensure your IME is done correctly, then call us toll-free for a free initial consultation at 1-888-494-7191. Our staff is available 24/7 to speak with you and walk-ins at our office in downtown Calgary are also welcome.