What to Do if Your Doctor Disagrees with the Insurance Company's Evaluation

John Larrimer
Jan 1
4 min read

It's not unheard of for insurance companies to dispute and deny claims. Unfortunately, it is quite common, particularly when it comes to medical claims that don't require prior authorization before the treatment.

Many insurers end up requesting an Independent Medical Examination (IME) from a doctor of their choosing, who will say your injury was not that severe or that the medical treatment you received was not up to their standard. The end result? Claims are either denied or reduced.

We're here to tell you what to do when the insurance company disagrees with your doctor, the IME process is initiated, and if your doctor disagrees with the insurance company's evaluation. We can also explain what to do if you can’t return to work after an injury.

Why Would a Health Insurer Request an Independent Medical Examination (IME)?

There are various reasons why an insurance company may do this, such as:

1. To Assess the Magnitude, Lifelong Impact, and Severity of the Injury

An insurer will always try to limit its financial liability. When it comes to a debilitating or long-term medical condition, they tend to question the severity. An insurance company's evaluation may claim that:

The condition doesn't require ongoing treatment as it isn't permanent.
You are recovering at a rapid pace.
You will be able to return to work sooner than your doctor mentioned.

2. To Confirm the Initial Treatment and Diagnosis

Before they approve or deny medical treatment claims, the insurance company may need a bit more clarity on the matter at hand.

An IME can be used to either confirm or deny what your doctor concluded and the recommended medical care. If the IME doctor disagrees with the extent of your condition, your health insurance coverage may be discontinued or canceled, or any future claims for medical bills may be denied.

What is often seen is that the insurance company disagrees with the treatment performed. This results in them denying the claim based on medical necessity, as they state that the treatments your doctor performed were not medically necessary. For additional guidance through your claim, top-rated workers comp attorneys in Columbus may be able to help.

3. To Determine Whether There Were Any Pre-existing Conditions Before the Incident in Question

A clear and common tactic implemented by insurance companies is to use an IME to blame a pre-existing condition for the pain or injuries experienced in the accident at hand.

This is often seen in personal injury cases that deal with chronic pain, joint issues, and back pain.

Getting a Second Opinion from Your Doctor

If the IME has been initiated and finalized, it could be a good idea to schedule a follow up appointment with your treating physician for a full and fair review of the IME results. Oftentimes, your doctor will not agree.

Your physician can perform updated medical tests to either confirm or challenge what's in the IME report. Ensure that your doctor's findings are clearly documented in writing.

All this additional information will strengthen your case and help you build a more compelling argument that will work in your favor when it comes to getting your claim approved.

What to Do if Your Doctor Disagrees with the Insurance Company's Evaluation?

If you and your doctor disagree with the IME report, it's essential to take action as soon as possible.

Get your doctor to take note of any contradictions, inaccuracies, or missing information. Perform a comparison of the IME report to your doctor's findings and medical records.

Obtain Legal Help

Now, it is time to get a lawyer involved. An IME request is generally an indication that the insurance provider is trying to undermine your claim. Legal counsel might be required if the IME produces an unfair report or if the insurance company is utilizing it to postpone or reject your claim.

Have your attorney challenge the validity of the report, specifically if it contains inaccurate or biased information. They can also advise on what to do if you’re fired after filing a workers’ comp claim.

Some of the steps an attorney can take include:

Conduct a cross-examination of the IME doctor, particularly with regard to their history of working for insurance companies.
Provide medical records or evidence that contradicts the IME report and highlights its inaccuracies.
Request a new IME and a new, unbiased doctor if you believe the first one did not perform an appropriate review.

Initiate the Appeals Process

You don't have to take the IME findings as gospel. It is not the final decision, especially if the report is inaccurate or misrepresents your injuries and affects the claims process for fair compensation.

An insurance denial is not unheard of. Therefore, it is often possible to file a formal dispute with the health insurer to get your claim approved.

You can either file for an internal appeal or an external appeal. Filing an internal appeal is often the first line of defense.

Therefore, you may file an internal appeal if the insurance company still disputes your claim after taking into account a second opinion and presenting more proof. Examine the insurer's appeals procedure and send in any supporting evidence as soon as possible. To ensure that your appeal is carefully considered, be tenacious and follow up.

An external review means that the matter goes to an independent third party for the final say and that the insurance company no longer gets a say over the benefits or compensation received.

It's crucial to proceed bravely when the insurance company disputes your doctor's medical report. Being aware of your rights and obligations in these circumstances gives you the ability to speak up for your own well-being.

Are You Dealing with a Difficult Insurance Company? Contact Larrimer & Larrimer Today for a Free Consultation!

Despite medical records, insurance companies are known for being difficult and wanting to lowball any insurance claims. This is the last thing anyone wants to deal with when they're injured or unwell. That's why, when it comes to a medical claim, let the attorneys handle it while you get better.

At our law firm, our attorneys are dedicated to ensuring that your rights are protected and you are treated fairly. Therefore, if you find yourself in this difficult situation, give us a call today!