Guidelines for Independent Medical Evaluations
A. Attending Physician (“AP”) Related. If a determination is made that the medical information in the claim file lacks clarity or sufficiency in assessing the insured’s medical condition in order to validate the claim under the requirements of the applicable policy or if the Company has reason to question the opinions or information provided by a claimant’s AP, the appropriate Company medical professional should contact the AP either by phone or by letter for clarification or additional information. If a telephone contact cannot be arranged, a letter outlining the question(s) and issues should be sent to the AP, which invites a reply either by phone or by letter.
Following such contact, if the Company’s medical professional and the AP are unable to reach an agreement on the medical issue or issues and its or their effect on the claimant’s capacity for work an independent medical evaluation should be sought under the following guidelines unless the decision is made to pay or continue to pay the claim:
- An independent record review should be sought whenever the lack of agreement primarily concerns an issue of data interpretation, and therefore an examination of the claimant would not be useful to understand the allegedly impairing condition.
- An independent medical examination (“IME”) of the claimant should be sought whenever there is lack of agreement and the opinion of the Company’s medical professionals involved in the claim file is the primary basis for the denial or termination of benefits unless the following conditions are satisfied in which instance an IME need not be sought, and the claim file is documented with regard to these conditions being satisfied:
i. The Chief Medical Officer (“CMO”) of the Company or one of the Company’s certified medical specialists with the highest level credentials in the specialty field in the Company relating to the claim and designated by the CMO to perform such reviews (“DMO”) has reviewed the specific claim, focusing particularly on the area or areas of disagreement between the AP and the Company’s medical professionals involved in the claim file,
ii. The CMO or the DMO reviewing the specific claim file performs his or her separate analysis of the issue or issues upon which there is disagreement, including any other information in the file deemed by the reviewing CMO or DMO to be relevant to the claim decision, and
iii. The CMO or the DMO reviewing the specific claim file concludes that there is reasonable medical certainty supporting the position of the Company’s medical professionals involved in the claim file and in disagreement with the AP, after having determined that the AP’s opinion is not well supported by medically acceptable clinical or laboratory diagnostic techniques and is inconsistent with the other substantial evidence in the claim file.
If the CMO or the DMO reviewing the specific claim file is unable to reach the conclusion set forth in subparagraph 2.iii. above, then an IME should be performed.
If the CMO or DMO agree with the AP’s opinion, there is agreement as to the current existence of a disabling condition and no IME is needed at the present time.
B. An IME (or in circumstances relating to an issue of data interpretation in which case an independent record review) should be sought whenever any of the following occurs unless the decision is made to pay or continue to pay the claim:
- A prior IME found disabling limitations and the current impairment is based on the same limitations;
- A Company medical professional or other Company resource, e.g., legal/compliance, Benefit Specialist responsible for the claim, states that an IME is needed;
- There is a difference of opinion between two or more of the Company’s medical professionals with respect to the existence of a disabling condition; or
- The claimant or the AP requests an IME, either directly or through the claimant’s representative.
C. An IME must be obtained and conducted on the basis of objective, professional criteria:
1. The Company shall select individuals to conduct IME’s solely on the basis of objective, professional criteria, and without regard to results of previous IME’s conducted by such individuals; and,
2. Neither the Company nor any of its officers or employees shall attempt to influence the impairment determinations of professionals conducting IME’s.