The Role of Independent Medical Exams in Workers' Compensation Disputes

When a worker gets hurt on the job, workers' compensation benefits can help cover medical expenses and lost wages. But sometimes, disputes arise over the severity of an injury or the treatment needed. Insurance companies and employers may question whether a worker's condition is as serious as claimed. 

In these situations, an independent medical exam (IME) often plays a key role in resolving disagreements. While IMEs are meant to provide an objective medical perspective, they can also be a source of frustration. Fortunately, Armstrong Law Offices, P.S. in Kent, Washington, can help you prepare for what's ahead and protect your rights.

What an Independent Medical Exam Is and Why It's Requested

An IME is an evaluation performed by a physician with no prior relationship with the injured worker. This doctor evaluates the injury and provides an opinion on matters like diagnosis, work restrictions, and treatment needs. These exams are typically requested when there are disputes in a workers' compensation case. Some common reasons an IME may be ordered include:

• Questioning the severity of an injury: The insurance company may believe the worker’s injury isn’t as serious as reported. The IME doctor may assess whether the worker's symptoms align with the type of injury sustained. If the IME determines the injury is less severe than reported, the worker may face challenges in receiving benefits.

• Concerns about treatment recommendations: If a treating doctor suggests expensive or ongoing treatment, the insurer may want a second opinion. The IME doctor may be asked whether the treatments are necessary or if alternative treatments would be more appropriate.

• Determining maximum medical improvement (MMI): The IME doctor may be asked to evaluate whether the worker has recovered as much as possible. MMI is the point at which an injury isn’t expected to improve further. Benefits for ongoing treatment may be limited, and permanent disability ratings may be assessed.

• Assessing work restrictions: Employers or insurers may want clarification on whether a worker can return to their job or perform modified duties. If the IME doctor believes the worker is capable of returning to work in some capacity, even with restrictions, the employer may offer light-duty work.

• Disputing a connection to work: The employer or insurer might claim that an injury wasn't caused by work activities. If there’s any doubt about whether an injury is work-related, an IME may be used to assess whether the condition could have resulted from a pre-existing condition, non-work activities, or a degenerative disease.

Understanding these reasons can help injured workers anticipate when an IME might be required and prepare accordingly.

Who Chooses the IME Doctor and What That Means for Workers

In most cases, the insurance company or employer chooses the IME doctor. This can create concerns about impartiality since the doctor is paid by the insurer and may have a history of siding with them. Workers should be prepared for the possibility that the IME report may not align with their treating physician’s opinion.

That said, workers aren’t completely powerless in this process. If an IME doctor’s report seems inaccurate or biased, they can present evidence from their own doctor, request another exam, or challenge the findings through legal avenues. Understanding who selects the IME doctor helps injured workers anticipate potential hurdles in their case.

What Happens During an IME

IME appointments are typically different from regular medical visits. These exams are focused on evaluation rather than treatment. During an IME, workers can expect the following:

• A review of medical records: The doctor will examine medical records, including prior treatments and test results.

• A physical examination: The doctor may conduct tests to assess the injury and physical limitations.

• Questions about the injury: The IME doctor will ask about how the injury occurred, current symptoms, and work-related limitations.

• Observations of physical behavior: The doctor may note how a worker moves before and after the exam, looking for inconsistencies.

• A written report: After the exam, the doctor will submit a report with their conclusions, which could impact benefit eligibility.

Because IMEs are meant to assess rather than treat, workers should approach them with a clear understanding of their purpose and potential impact.

How IME Findings Can Affect a Workers' Compensation Claim

The IME report carries significant weight in a workers' compensation case. The findings may support or challenge a worker’s claim, which can impact benefits in several ways:

• Approval or denial of benefits: If the IME supports the worker’s claim, benefits may continue as usual. However, if the IME doctor determines that the injury is less severe than claimed, the insurance company may reduce or completely deny benefits. A denial can leave a worker without medical treatment coverage and lost wage compensation.

• Changes in treatment plans: The insurer may use the IME report to challenge or limit certain treatments. For example, if a treating physician recommends surgery, but the IME doctor believes physical therapy is sufficient, the insurer may deny coverage. This can delay or prevent workers from getting the treatment they need to recover fully.

• Work status determinations: The IME may influence whether a worker is cleared to return to work, with or without restrictions. If an IME doctor decides a worker can return to full duty despite ongoing symptoms, the employer may pressure them to resume work before they feel ready.

• Legal disputes: If the IME contradicts a treating physician’s opinion, the case may proceed to a hearing or appeal. Workers who receive an unfavorable IME report may need to provide additional medical evidence to dispute its findings.

Since the IME report can significantly impact a claim, workers should be aware of its potential consequences and plan their next steps accordingly.

Steps Workers Can Take to Prepare for an IME

Since an IME can affect the outcome of a workers’ compensation claim, it’s important to be prepared. Some steps that may help include the following:

• Review medical records beforehand: Knowing past diagnoses, treatments, and test results can help workers answer questions accurately.

• Be honest but concise: Giving too little or too much information can lead to misinterpretation. Clear and factual responses are best.

• Take note of symptoms and limitations: Keeping a journal of daily challenges can help workers describe their condition more effectively.

• Bring a witness if allowed: Having a trusted person present may provide additional documentation if disputes arise later.

• Follow up with a treating doctor: If the IME report contains inaccuracies, a treating physician can help correct them with additional medical evidence.

Taking these steps can give workers a better chance of accurately representing their condition during an IME.

What to Do If an IME Report Is Inaccurate

If an IME report contains errors or appears biased, workers have options to challenge it. Steps that may help include:

• Obtaining a second opinion: A worker’s own doctor can provide an alternative evaluation to counter the IME findings.

• Requesting a hearing: If benefits are reduced or denied, workers can appeal the decision and present evidence before a judge.

• Providing additional medical records: Detailed records from a treating physician can help dispute an IME’s conclusions.

• Seeking legal representation: An experienced attorney can help injured workers address unfair IME findings and advocate for their rights.

Workers who believe an IME report is inaccurate should act quickly to gather evidence and protect their claim.

Contact Us Today

Independent medical exams play a significant role in workers' compensation disputes, often determining whether injured employees receive the benefits they need. When an IME report threatens your workers’ compensation, turning to the aid of Armstrong Law Offices, P.S. in Kent, Washington, can make all the difference.

Attorney James Armstrong also serves clients in Seattle, Tacoma, and Renton, Washington. Call today for a free and confidential consultation.