Independent Medical Exam After a Car Accident: What to Expect

An independent medical exam, or IME, is an examination by a doctor the insurance company chooses, used to check whether your injuries and treatment are related to the accident and still medically necessary. In no-fault and PIP claims, going to a reasonably requested exam is generally a condition of your coverage. Missing one can let the insurer stop paying future benefits, so treat the appointment as seriously as the claim itself.

Despite the name, the doctor is not working for you. The insurer selects and pays the examiner, and the report goes to the insurer. That does not make the exam unfair by default, but it does mean you should go in prepared.

Why insurers ask for one

Insurers use these exams to verify a claim, most often to decide whether ongoing treatment is necessary. New York's no-fault policy endorsement says the injured person shall submit to medical examination by physicians selected by, or acceptable to, the company, when and as often as it may reasonably require. New York's Department of Financial Services has said this makes attending a reasonably requested exam a condition precedent to coverage, and that an insurer may request one even before it has received your written application for benefits.

The examiner does not have to share your treating provider's specialty. New York regulators concluded that a medical doctor may examine a patient whose chiropractic treatment is in question, though an arbitrator or court may consider the examiner's qualifications when judging a denial based on the exam.

What happens if you miss it

The consequences are significant, and they are spelled out in state rules:

• In New York, failing to attend a reasonably requested exam can let the insurer deny pending claims and relieves it of covering future health services from that accident, though it should still pay claims whose necessity it does not dispute
• In New York, missing an exam does not give the insurer a right to take back benefits it already paid
• In Florida, if you unreasonably refuse or fail to appear, the PIP insurer is no longer liable for subsequent PIP benefits
• In Florida, refusing or missing two exams creates a presumption that the refusal was unreasonable, which you would have to overcome

New York also protects people who miss one appointment. Its regulators have said that when an exam is requested as part of verifying a claim and you miss the first one, the insurer must try to reschedule and give you a second opportunity, and it cannot send a conditional denial that is withdrawn only if you attend. If you cannot make the date, contact the insurer before the appointment and ask to reschedule, in writing.

Rules about cost and location

Florida's PIP statute gives injured people specific protections. The insurer bears the entire cost of any exam it requests. The exam must be held in the municipality where you are receiving treatment, or in a location reasonably accessible to you, which the statute defines as within the municipality where you live or within 10 miles by road of your home in your county. If no qualified physician is available that close, it is held in the closest area to your residence.

Other states set their own rules. If you are asked to travel far or pay anything, ask the insurer which rule it is relying on.

After the exam

If the examiner concludes that further treatment is not necessary, the insurer may cut off future benefits. How that cutoff works is regulated. In New York, regulators have said the date the exam is performed is treated as the date the insurer received the verification, the insurer then has 30 days to pay or deny, and the earliest date benefits can be cut off going forward is the date the denial is sent to you.

In Florida, an insurer cannot simply stop paying your treating physician without your consent. It first needs a valid report from a Florida physician licensed under the same chapter as your treating provider stating that the treatment was not reasonable, related, or necessary.

How to prepare

• Confirm the date, time, and address in writing, and ask the insurer to reschedule early if you have a conflict
• Bring a list of your symptoms, treatment dates, providers, and medications
• Answer questions honestly and consistently with your medical records, without exaggerating or minimizing
• Describe how the injuries affect your daily activities and work in concrete terms
• Afterward, write down how long the exam lasted and what was examined
• Ask the insurer for a copy of the report, and share it with your treating doctor

If benefits are denied after an exam, ask for the denial in writing, talk with your treating provider about whether to submit a rebuttal, and use your state's dispute process. In New York that includes no-fault arbitration. A licensed attorney in your state can explain your options if the amounts are large.

The bottom line

An insurer's medical exam is a routine but high-stakes part of a no-fault or PIP claim. Attending a reasonable request is generally required, missing it can end future benefits, and states such as Florida and New York put rules on cost, location, rescheduling, and cutoffs. Show up prepared, document the visit, and push back through the formal dispute process if the report is used to deny care your doctor says you need.