No-Fault Collections IME Denials

Independent Medical Examination Denials

Whenever any person puts his or her mental or physical condition at issue in any case which compensation is sought, insurance companies have the right to have a physician of its own choice to examine the client. Normally, insurance companies accomplish this by obtaining what is known as an IME, which is a medical examination of the patient that is conducted by a doctor who is paid by the insurance company to conduct the examination.

No Fault Collections – IME Denials – Lack of Medical Necessity

The purpose of an IME is for the insurance company to verify, by having its own doctor examine the patient, that the services provided for the injured party were medically necessary; additionally, IMEs can be used for the purpose of determining whether or not medical benefits for the injured party will continue. After the IME is conducted, the doctor puts together a report, called an “IME Report,” and submits the report to the insurance company to review. The report generally contains the doctor’s findings during the examination, and whether or not in the doctor’s opinion, the medical services in question were medically necessary and if any future treatment is warranted.

Generally it is hard to believe that these examinations are in fact “independent” of what the insurance companies are claiming to be medically necessary. At Choudhry and Franzoni Law Firm, we ensure that every denial based on the results of an IME made by an insurance company is opposed, if the treating physician disagrees with it. We specialize in collection of these denials based on IME.

If after the IME, the insurance company denies the claim, this does NOT mean that the treating medical provider must stop treatment, or that there will be no payment for services. If the patient’s symptoms remain, and it is the opinion of the treating physician that medical treatment is warranted, then medical treatment should be continued. After an IME denial, medical treatment can still be rendered, and all bills can be litigated or arbitrated. 97.5% of IME denials DO NOT hold up in court or arbitration, and the insurance companies are required to pay the treating physicians.

No Fault Collections – IME No Show Denials

According to New York insurance regulations, insurers are entitled to IMEs as “additional verification” following the receipt of a medical provider’s claim forms; this verification process works to rule out any potential fraudulent claims. All medical examinations requested by the insurer are held at a place and time reasonably convenient to the patient, and the patient will be reimbursed for any loss of earnings and reasonable transportation expenses incurred in complying with the request.

Insurance companies must request verification not once, but TWICE, before it is able to deny a claim. Therefore, if the patient does not comply with the requested verification the first time, before the insurance company denies the claim, it must issue a second request for the verification. If that second request is not complied with, then the insurance company may deny the claim.

Steven Fogel Psychological, P.C. v. Progressive Case. Ins. Co.is the lead case on IME no-shows in New York as of 2006. Before Steven Fogel, the rule was that the earliest date that insurance companies were permitted to cut off benefits based on IME no-show, is the date of the SECOND no-show. In other words, benefits could not be cut off retroactively.In 2006, the Court concluded that an insurer may deny a claim retroactively to the date of loss for a claimant’s failure to attend IMEs when, and as often as, the insurer may reasonably require. But even Steven Fogel Case law does not give insurance companies a rock-solid basis for automatically denying claims. HOWEVER THIS IS NOT THE END.

No Fault Collections – IME No Show Denials Can be Won

The Insurance Department has issued a clear in an opinion letter dated 2/14/05 in stating that if a patient fails to show up for an IME twice, BUT offers a reasonable excuse for not attending the examinations, and is attempting to establish (in cooperation with the No-Fault insurer) a reasonably convenient time to attend, then insurance companies must wait to deny the claim.

Excuses that have been found to be reasonable are the following:

IME was scheduled at an inconvenient time or an inconvenient place
Work or school schedules conflict with the scheduled IME
Over Lapping IME appointments
Family emergencies
Bad weather
(This is NOT an exhaustive list – There may be additional valid excuses)

In other words, Courts tend to be liberal in excusing the IME no-show if the patient shows that he is attempting to cooperate with the insurance company in rescheduling another appointment, and is acting in good faith even after the two IME show appointments

ADDITIONALLY, the insurance carrier must show evidence that requests for such IMEs were mailed to the injured person. If insurance company fails to show that requests for IMEs were mailed twice we may win because the carrier failed to carry its burden. If the insurance carrier is able to prove that the IME requests were properly mailed, the insurer must then present evidence that the injured party actually failed to attend the IME in both instances. We know how to discredit an insurance carrier’s evidence and frequently win because the carrier failed to carry its burden to show with certainty that both IME requests had been sent and that the injured party had failed to attend.

Choudhry & Franzoni Law Firm – No Fault Collection Lawyers