When you file an insurance claim or a lawsuit over an injury, you're putting your physical health -- and to some extent, your medical history -- at issue, so you need to be prepared to share some health-related information with other parties throughout the process. In this article, we'll explain a few common procedures in injury claims as they relate to medical records and medical examinations of claimants, including requests for medical “records” versus “reports,” and what to expect when it comes to an Independent Medical Examination.
Request for Medical Records
Although you will have sent copies of all your relevant medical records along with your demand letter, the adjuster might ask for some additional record you have not provided. For example, if X-rays were taken but you’ve provided only the records from your doctor and not from the radiologist, the adjuster might ask for the radiologist’s records. Or if there is an indication of a preexisting injury, an adjuster might ask to see medical records concerning that injury.
It is up to you to decide whether the request is reasonable. If it seems to be, tell the adjuster that you will provide the records if the insurance company is willing to pay for them. There is often a small fee from the doctor’s office for copying records. If the adjuster agrees to pay for the records, confirm the agreement in writing. Then request the records yourself and review them before sending them on to the adjuster, removing any records that do not pertain to accident injuries.
Unfortunately, some adjusters like to get additional medical records just to snoop around in your medical history to see if there is anything they can use against you or use to embarrass you. If the request for additional medical records seems unreasonable -- that is, is not related to the injuries you suffered in the accident -- do not comply. Ask the adjuster to explain why the additional records are needed. If the answer doesn’t convince you, politely inform the adjuster that you do not believe the records are relevant to your claim and that providing them would intrude into your privacy. Remind the adjuster that if the claim winds up in court, the lawyers will be able to argue over this issue, but that at this point you can see no reason to allow prying into your personal medical history. Be firm with the adjuster. There is nothing wrong or suspicious about protecting your privacy.
Request for Medical Report
The records that doctors regularly keep may not explain fully enough some medical issue important to your claim. For example, your medical records may not make it clear how much of your injury treatment is the result of an accident and how much is the effect of a preexisting injury. Or the prognosis for time of recovery may not be included. Or the doctor may have told you something about long-term effects from your injury but not included it in your medical records.
You or the adjuster may want a report from your doctor to clarify some medical issue. If the adjuster asks for a report and the request seems reasonable, do not allow the adjuster to contact your doctor directly. Tell the adjuster you will consider the request and will give an answer within a certain amount of time -- a week or two. Then contact your doctor and find out whether the doctor would write a report favorable to you. Also find out how much the doctor would charge for the report.
If the doctor indicates that the report might do you some good, you can contact the adjuster and agree to request a report if the adjuster agrees to pay for it. If the adjuster says yes, send a confirming letter.
Request for Medical Examination
Once in a while, a claimant and an adjuster will have widely different opinions about the seriousness of an injury. Most disagreements arise over long-term or permanent effects that the adjuster does not believe are as serious as you describe them to be. Usually this difference of opinion can be resolved in negotiations. You and the adjuster each compromise and meet at a settlement figure somewhere in the middle. But sometimes the difference of opinion is so wide that the adjuster will ask whether you would be willing to be examined by a doctor, designated by the insurance company, to provide another medical opinion about your injury. Because the insurance company has to pay a doctor for such an examination, cost-conscious adjusters do not request them very often.
Although these second opinions are referred to by insurance people as “independent medical examinations” (IMEs), they are anything but independent. The doctors who conduct the examinations are chosen -- and paid -- over and over again by insurance companies because they almost never find anything seriously wrong with an insurance claimant.
An IME is usually a bad idea for an insurance claimant. Fortunately, you are not required to submit to an IME, except, sometimes, under your own automobile policy. If an adjuster asks if you are willing to have an IME, politely refuse on the grounds that you do not wish to be examined by a doctor you do not know and whose opinion you have no way of judging. Remind the adjuster that if your claim later winds up in court, the insurance company can then follow the appropriate legal procedures to request an IME. Once a lawsuit is filed, the other side can get a court order compelling you to submit to an IME.
This article is an excerpt from How to Win Your Personal Injury Claim by Attorney Joseph Matthews (Nolo).