Can an insurer require you to be evaluated by their doctor when treatment is partway done?

Question

Last summer I was rear ended while stopped by a big truck with a solid steel bumper while I was in my 2003 Hyundai. Over the next few months I developed back pain and stiffness, along with sciatica. I started seeing a chiropractor after filing a claim with my insurer (who told me this was procedure, and they would get reimbursement from the other party's insurance.) Now, several months later, I'm in a lot less pain and my treatments are about every 2 weeks instead of the twice weekly I was starting with. Now my insurer wants to have an independent doctor evaluate me to "confirm" my injury. Since my injury is mostly healed, I am certain they are going to use this as an excuse to cut off my treatment before it is finished, maybe even try to bill me for treatment. Is this legal? Can I deny their demand and tell them my treatment is almost done so an evaluation would be unfair at this point?

Mr. Michael O. Stevens · Answer

Yes, they can require this. If you review your policy I can guarantee you there is a clause that says you have to cooperate with your carrier, and that you must submit to what we call an IME. If they make you start going to a lot of them, then you might consider talking to an attorney to see at which point you might consider not agreeing to an IME.

Jina Ly Clark · Answer

If you want your insurance to continue to pay for treatment, you will need to go to the insurance doctor.  If you don't, they will claim you are in breach of contract and cut off treatment.  However, you are right.  They will likely use the insurance doctor's report as an excuse to cut off treatment.  The report that the insurance doctor writes will also be available to the at-fault insurance company if you were not at-fault for this accident and file a lawsuit.  Our firm's policy is to determine if going to the insurance doctor is a wise choice on a case by case basis.  I normally contact the treating doctor and try to come to a consensus on a game plan using my legal knowledge and his/her medical knowledge.  If you were at-fault for the accident, I recommend you speak with your treating doctor and get his recommendation.  Some treating doctors are willing to go to bat for their patients and are willing to write a responsive report to the insurance report.   If you were not at fault for the accident, you might consider getting an attorney at this juncture to confer with your treatment provider regarding the best response.

Virgil Royer · Answer

Your insurance company can demand that you submit to a medical examiner for an independent medical examination (IME) per your contract with the insurance company to ensure the that the treatment you receive is medically necessary for injuries related to the accident. If you fail to attend, then you are in breach of your contract and they can withhold payment and not allow treatment under the agreement. However, if you attend the IME and the medical examiner states that the treatment is not reasonable, you can provide evidence to refute that finding. You should ask your current provide to defend their treatment plan. sometimes, you can ask them to hold off on demanding an IME by providing a specific date for termination of treatment, as it may be more cost-effective than paying for an IME.

Q: Can an insurer require you to be evaluated by their doctor when treatment is partway done?