Independent Medical Examinations
When a claimant claims an injury that does not agree with the facts of the incident claimed to have caused the injury, the adjuster will often seek the assistance of an Independent Medical Examiner (IME) to verify the extent of the claimed injury. The IME is usually a forensic physician or a chiropractor who has agreed to evaluate an injured person for a fee and is not involved in the treatment of the injured person.
In Pennsylvania, an insurer providing medical benefits to its insureds following an automobile accident did not have to establish good cause before the insureds were required to take physical examination administered by doctor of insurer’s choice, even though statute provided generally that insurer seeking to compel independent medical exam was required to show good cause; policy gave insurer right to order examination without establishing good cause. [Fleming v. CNA Ins. Companies, 409 Pa. Super. 285, 597 A.2d 1206 (1991)].
When an insurer’s adjuster testified that he was told by his supervisor at TOP that the purpose of a claims department was not to find ways to pay claims, but to find ways to deny claims. Thus, based on Dr. Ramey’s report, he felt that there was sufficient information to deny plaintiff’s claim, and that it was unnecessary to consider any other information.
The truth was the opposite of what the insurer testified to: the purpose of a claims department is to find ways to pay, not to deny, claims. The $5 million verdict that resulted in the Sprague case made insurers much more careful when they ordered independent medical exams in California and, hopefully, will never again tell an IME what to conclude after doing the examination.
© 2020 – Barry Zalma
Barry Zalma, Esq., CFE, now limits his practice to service as an insurance consultant specializing in insurance coverage, insurance claims handling, insurance bad faith and insurance fraud almost equally for insurers and policyholders. He also serves as an arbitrator or mediator for insurance related disputes. He practiced law in California for more than 44 years as an insurance coverage and claims handling lawyer and more than 52 years in the insurance business. He is available at http://www.zalma.com and firstname.lastname@example.org.
Mr. Zalma is the first recipient of the first annual Claims Magazine/ACE Legend Award.
Over the last 52 years Barry Zalma has dedicated his life to insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to make it possible for insurers and their claims staff to become insurance claims professionals.
Read posts from Barry Zalma at https://parler.com/profile/Zalma/posts