Needing surgery, but having to go to an IME first

Sometimes insurance companies can send you for an Independent Medical Evaluation (IME), to get a medical opinion about the cause or extent of your injuries, or about the need for treatment.  These physicians that they hire for the IME are usually honest, but they are hired by the insurance company and may not always be as “independent” as they seem or should be.

Though this shouldn’t happen, sometimes the IME can deny or delay treatment that you need.  A reader fearing this would happen, asked us what he should do.

He hurt his back three months ago, and has a herniated disc.  Workers’ compensation had been covering his medical expenses, but he is still in a lot of pain and his doctor is recommending surgery.  The insurance company is sending him for an IME, but he heard that the IME doctor was a hired gun.  His concern, therefore, is what will happen if the IME doctor says that he is fine or that they aren’t responsible, and won’t cover treatment.

If you’re in a situation like this, it’s most important that you get the treatment that you need.  Be honest with your doctors, and let your lawyers help you to get the payment worked out.  We are able to file the case and request payment for the treatment.  If your doctor is recommending surgery, we can ask the Arbitrator to order it and for the insurance company to pay the cost.  Or, in the worst scenario, where you need the treatment before we go to trial, you can pay for it through your own insurance, and we can still go ahead and prove your case.

Sometimes the insurance company has a genuine disagreement about whether you need the treatment, or whether they need to pay for it.  Even if the IME physician is a hired gun, the insurer may still legitimately believe that they shouldn’t have to cover your treatment.  Going ahead with your case should take care of this, and get you the payment you’re entitled to.

But if the insurance company is unreasonably denying your benefits, not only should they pay for your treatment costs, but they should pay you a penalty as well.  The insurer could be ordered to pay you 50% of the amount of your treatment costs for refusing or delaying your payment, if their actions were unreasonable or with bad intentions.  For example, if your surgery would cost $30,000, the insurance company may be ordered to pay you $15,000 for their behavior.

It’s most important for injured workers to get the treatment they need, and to do it in the proper time frame for it to be successful.  That’s why, even with a hired gun for an IME provider, you should still be able to get the result you are entitled to.

We are workers' compensation attorneys that help people with Illinois work injuries anywhere in IL via our statewide network of attorneys.  Contact us and we will answer your questions or find the right lawyer for your situation.

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