Nearly every disability insurance policy contains a provision giving the insurance company the right to have a claimant (a person who has filed a disability insurance claim) examined by a doctor of its choosing. That same provision generally includes that if a claimant fails or refuses to attend an examination requested by the insurance company that benefits may be denied or suspended. As such, if you file a claim for disability benefits on the basis of a medical condition interfering with your work abilities, the insurance company generally has a right to “investigate” the medical condition that you claim disables you under the policy.
However, this does not mean that an insurance company is free to abuse this provision by attempting to enforce or interpret the provision in an unreasonable manner and beyond the provision’s actual purpose and meaning. There are many reasons why an insurance company’s request to enforce this provision and require an “examination” should be aggressively challenged. For instance, the examination should be with a medical professional appropriately trained to evaluate the type of medical condition at issue, the examination should be scheduled within a reasonable distance of a claimant’s residence and at a time convenient for the claimant, the testing requested must be safe for a claimant to undergo in light of his/her medical condition, and the examination should be requested by the insurance company at the appropriate stage of its evaluation of a disability claim. This is not an exhaustive list, and whether an insurance company’s request for an examination is reasonable depends on the facts and circumstances unique to each individual case. However, it is critical to be aware that an insurance company is permitted under the law to reasonably enforce these provisions and require an examination by an appropriately trained medical specialist – a refusal by a claimant to undergo such an examination can result in a denial or suspension of disability benefits on this basis alone. Courts will agree that an insurance company was permitted to deny or terminate benefits in this situation where such provision exists in the policy, unless there is a very good reason for a claimant’s refusal or failure to undergo the examination. A refusal by a claimant to cooperate must be handled in a very careful and strategic manner to remain compliant under the law so as to not interfere with a claimant’s right to receive continued benefits under the policy.
If the examination requested is to occur, certain precautions in agreeing to undergo the examination are a must. These examinations scheduled by insurance companies are anything but independent, and are performed by their regular “hired guns” who receive a large percentage of their income from performing examinations at the request of insurance companies such as yours. The “hired guns” performing these examinations at an insurance company’s request regularly participate in twisting the words of the claimant being examined, misrepresent what a claimant did during an examination, intentionally neglect to report certain information obtained during the examination which would serve to support the claimant’s disability claim, and go beyond the scope of the medical evaluation in their report to attack a claimant’s credibility and disability claim. Furthermore, the doctor chosen by the insurer may only take 10-15 minutes to conduct his or her entire “independent evaluation” of the claimant, including the interview process and the “examination” itself. The doctors paid by the insurance company (who are motivated to please the insurance company who pays them an exorbitant amount of money to perform these “independent” examinations) do not wish to discover or be made aware of evidence that supports a claimant’s disability claim by way of conducting a more thorough examination.
Beware that insurance companies also use this as an opportunity to hire an undercover surveillance team to follow a claimant to and from the examination and videotape you the entire time. If the surveillance videotape shows any level of activity, rest assured that it will be provided to the insurance company’s hired “independent” doctor for comment in his/her report being drafted following the “independent” evaluation. If the surveillance videotape does not show activity or shows evidence of a claimant’s restrictions and limitations, it will not likely be provided to the “hired gun.” In this situation the insurance company will not likely admit that surveillance videotape was ever conducted, despite it supporting the disability claim – however, a skilled attorney should be able to determine whether surveillance was conducted and whether it supported the claim for benefits and use as support for payment of the disability claim.
Any request for an examination by an insurer in a disability insurance claim must be taken very seriously, and be quickly and aggressively handled. How such a request should be responded to varies greatly based on the unique circumstances presented and must be scrutinized on a case-by-case basis. DI Law Group is regularly involved in dealing with insurer’s request for a examination with a physician of its choice, and not only aggressively requires that such a request and examination be reasonable under the policy provisions and the law, but has also successfully caused cancellation of such examinations where they were unreasonable while still preserving our clients rights to ongoing benefits under the policy. Furthermore, where an examination is permitted to go forward to ensure that our client’s right to ongoing benefits is preserved, it is aggressively managed and scrutinized by our experienced attorneys – the examination is only permitted to go forward upon agreement by the insurance company to very specific stipulations necessary to protect our client’s rights. We may require that the scope of the examination/evaluation be limited in scope, we may require that our client’s treating doctors are provided with the insurance company’s doctor’s report (which the insurance company will not normally release upon request by a claimant) upon completion to be allowed the opportunity to review and respond to the report, we may demand that a videographer or attorney be present for the entire examination, we may require the insurance company to provide transportation for our client to and from the examination, we may schedule our own independent medical evaluation of our client to dispute the insurance company’s doctor’s report and to provide evidence in support of the disability claim, among other strategies. Evaluations based upon psychiatric medical conditions have their own special considerations. We many times see the same doctors being used time and again by the insurance company to conduct these “independent” evaluations – we regularly utilize prior depositions, subpoenaed documentation, court decisions, and other information to dispute the “independence” of these doctors chosen by the insurer and we do so on the record. How these examinations requested by insurance companies are dealt with, however, is highly strategic and must be handled in an extremely cautious manner. If you have been requested by your disability insurance company to attend an examination, you may wish to contact an experienced disability insurance attorney for assistance. At DI Law Group, we provide a free initial consultation for claimants in this situation.