If your long-term disability insurer schedules an independent medical exam (IME), functional capacity evaluation, or another investigation, it does not necessarily mean your LTD benefits will be denied. It does mean the insurer is gathering evidence that could affect whether you continue to meet the policy's definition of disability.
The disability attorneys at Hawks Quindel, S.C. help individuals understand what to expect from LTD independent medical exams and insurer investigations, how the resulting evidence can affect a claim, and what options exist when that evidence contributes to a denial or termination.
Securing Disability Benefits Rightfully Owed to Wisconsin Workers
What Is an Independent Medical Exam for an LTD Claim?
An independent medical exam (IME) is performed by a physician other than your regular treating provider. The insurer generally selects or arranges for the examiner and may rely on the resulting report when evaluating your claim.
An IME can address your diagnosis, symptoms, functional limitations, treatment, prognosis, and ability to work. The scope depends on your medical condition and the questions the insurer wants the examiner to address.
The word “independent” can therefore be confusing. It does not necessarily mean you and the insurer jointly selected a neutral physician. What matters for your claim is what the examiner concludes and whether those conclusions accurately reflect your medical condition and ability to perform the work required under your policy.
Why Is the Insurer Requesting an IME?
An insurer may request an IME during an initial claim or after you have received LTD benefits for months or years. It may be seeking additional information about whether:
- Your reported restrictions are supported by medical findings
- Your condition continues to prevent you from working
- Your functional capacity has improved
- Your limitations satisfy the policy's occupational standard
The request itself does not determine whether benefits will continue. An IME becomes especially important when the examiner reaches conclusions that differ from those of your treating physicians.
How Should You Prepare for an Independent Medical Exam?
Preparation does not mean rehearsing answers or trying to perform poorly. Your goal is to provide accurate information about your condition and limitations.
Review the appointment instructions, your medical restrictions, and your medication information beforehand. Be prepared to accurately explain your symptoms, treatment, daily activities, and functional limitations.
Avoid both exaggerating and minimizing your condition. If you can perform an activity briefly but develop symptoms when you continue, explain that distinction. Being able to sit, walk, concentrate, or use your hands for a short period does not necessarily mean you can sustain these activities throughout a workday.
This distinction can be particularly important for chronic pain, fatigue, cognitive problems, and conditions with symptoms that fluctuate.
What Happens During an Independent Medical Exam?
The examination varies according to your condition and the examiner's specialty. It may include a medical history, a discussion of symptoms and treatment, a physical examination, tests, and questions about daily activities and work.
The examiner may also observe how you move and function during the appointment. Afterward, the physician generally prepares a report addressing the medical findings, reported limitations, and activities the examiner believes you can perform.
An opinion that you have some functional capacity does not necessarily establish that you can work. The relevant question is whether your capabilities satisfy the definition of disability in your LTD policy.
What Is a Functional Capacity Evaluation?
A functional capacity evaluation, or FCE, generally uses tasks and measurements to assess abilities such as sitting, standing, walking, lifting, carrying, or reaching. The results can then be compared with occupational demands.
How those results affect an LTD claim depends in part on the policy's definition of disability. Under an own-occupation standard, the analysis can focus on whether you can perform the material duties of your occupation. Under an any-occupation standard, other work meeting the policy's requirements may be considered.
Our Own Occupation vs. Any Occupation Disability Benefits resource explains these standards in greater detail.
An FCE should also be considered alongside medical history, symptoms, treatment records, physician restrictions, and appropriate occupational evidence rather than treated as the only measure of disability.
Can an Insurer Use Surveillance or Social Media?
Insurers sometimes use surveillance or publicly available information when evaluating disability claims. This can include observing activities outside the home or reviewing public social-media content.
Surveillance does not automatically establish that someone can work. A person with a disabling condition may still shop, exercise as recommended, attend family events, or experience good days among bad ones. A brief activity does not necessarily demonstrate an ability to perform occupational duties reliably throughout a full workweek.
Inconsistencies can nevertheless affect a claim. If someone reports being completely unable to perform an activity and other evidence shows otherwise, the insurer may use the discrepancy when evaluating functional capacity.
The practical response is not to stop living your life because you might be observed. Instead, describe your limitations accurately and consistently, follow appropriate medical advice, and recognize that public statements and activities may be considered with other claim evidence.
What if the IME Doctor Disagrees With Your Treating Physician?
A conflicting IME report should be reviewed closely rather than answered with a generic argument that your own doctor knows you better. Important questions include which records the examiner reviewed, what testing was conducted, which restrictions the examiner rejected, and what evidence supports those conclusions.
The report should also be compared with the disability policy and actual occupational demands. For example, an examiner might conclude that you can sit for several hours or perform light physical activity. That finding does not automatically establish that you can reliably perform all material duties required by the relevant occupation.
A treating physician may be able to address disputed findings, explain why restrictions remain necessary, or provide additional evidence. Vocational or occupational evidence may also help establish why documented restrictions prevent you from performing the work required under the policy.
What Happens if an IME Leads to an LTD Denial or Termination?
An insurer may rely on an IME, FCE, surveillance, medical record review, or several sources of evidence to conclude that you no longer meet its disability definition. If that results in a denial or termination, we must determine what evidence drove the decision.
For an employer-sponsored LTD plan governed by ERISA, the administrative appeal can be a critical opportunity to respond to adverse medical and vocational evidence and address the insurer's stated reasons for denying benefits. Federal regulations establish claims and appeal procedures for ERISA disability plans.
Simply resubmitting existing records may not answer the conclusions in an adverse IME. An effective response may require evidence that addresses the specific medical findings, functional conclusions, occupational analysis, or surveillance used against the claim.
Our Long-Term Disability Denial & Appeals resource explains the next stage after benefits are denied or terminated.
How Can an LTD Attorney Help During an Insurer Investigation?
You do not necessarily have to wait until your benefits are terminated to seek legal advice. The disability attorneys at Hawks Quindel, S.C. can review the policy, IME request, medical evidence, occupational standard, and claim materials to determine what the insurer is evaluating.
If an examination or investigation produces adverse evidence, our attorneys can analyze how it compares with your treating records and the policy requirements. If benefits have already been denied or terminated, we can identify the insurer's reasoning and develop an appeal when we can assist.
Hawks Quindel, S.C. represents individuals seeking disability benefits, not insurance companies or employers. Founded in 1959, our firm has spent more than 60 years advocating for workers and individuals whose benefits and financial security are at risk.
Frequently Asked Questions About LTD IMEs and Investigations
Can I refuse an LTD independent medical exam?
Your policy may require you to participate in reasonable examinations during the claim process. Refusing without understanding the policy requirements could jeopardize benefits. If you have concerns about an IME request, consider having the policy and request reviewed before deciding how to respond.
Should I bring medical records to my LTD IME?
Follow the instructions provided for the examination. The examiner may already have records from the claim file, but you should not assume which records were provided. Clarify the requirements beforehand if you are uncertain about what to bring.
Does surveillance mean my LTD claim will be denied?
No. Surveillance is evidence, not an automatic determination of disability. Its significance depends on what it shows, whether it conflicts with reported limitations, and how the activities relate to the policy's definition of disability.
Can my treating doctor respond to an IME report?
Yes. A treating provider may be able to address the IME's medical conclusions and explain why particular restrictions remain appropriate. A focused response to disputed findings can be especially important if the insurer relies on the IME to deny or terminate benefits.
Talk to an LTD Attorney at Hawks Quindel, S.C. to Learn More
An IME, functional capacity evaluation, or insurer investigation can affect whether your LTD benefits continue, but adverse evidence does not necessarily settle whether you are disabled under your policy.
The disability attorneys at Hawks Quindel, S.C. can review the investigation, medical evidence, occupational requirements, and policy language and explain your options. If an IME or investigation has led to a denial or termination, we can evaluate the decision and determine how to challenge it when appropriate.
Contact our team to begin the intake process and learn whether your matter qualifies for a free case screening. Call our Madison office at 608-257-0040 or our Milwaukee office at 414-271-8650, or fill out our confidential contact form.