Many employees in Chicago and throughout Illinois have experienced the frustration of dealing with an insurer during a claim for long term disability benefits. Add in all the complex statutes, regulations, and rules of ERISA (which governs most of these plans because it covers any group policy coverage obtained through your employer), and the process gets even more frustrating and confusing. So what do you do when the insurer notifies you during the claim review or appeal review that it needs you to attend an Independent Medical Examination?
An Independent Medical Examination is an in-person evaluation by a doctor. Such an exam is frequently used in workers compensation cases, and started being used in long term disability insurance review cases, too. The problem is that the insurer usually tries to unilaterally choose the doctor, who may be biased to return an opinion favorable to the insurer. Not uncommonly, then, claimants feel hesitant or anxious about attending an evaluation by a doctor who will likely act like an adversary. As much as you may feel reluctant to attend, failing to do so can cause a lot of harm to your claim. At best, it will delay the processing of your claim by a year or more, and at worst you will completely forfeit the long term disability benefits. One such case highlighted this outcome recently, luckily leaving the claimant with the better of the two undesirable results.
In Rogers v. Reliance Standard Life Insurance Co., No. 14 C 4029, 2015 U.S. Dist. LEXIS 59112 (N.D. Ill. May 6, 2015), Reliance Standard requested an IME after its deadline to review an appeal of a benefit termination had lapsed, though it missed the deadline by a few days. Ms. Rogers, upon receiving the late request, refused to attend the IME, despite the insurer stating it was necessary to evaluate her claim. She sued for the long term disability insurance benefits under ERISA § 502(a). Rogers argued Reliance Standard could not request an IME after it made a decision on the initial claim—and this was review of an appeal—and that the request was untimely anyway, thus excusing Rogers from having to attend. Reliance Standard argued that Rogers failed to exhaust her administrative remedies before filing a lawsuit because she did not attend the IME and did not appeal the most recent denial (though it was late).
Interestingly, the court rejected both arguments. It reasoned that the policy gives the insurer the right to request an IME during the claim review, and a review of an appeal is still part of the “claim” review process. Also, Reliance Standard’s tardiness by a couple days would not operate to preclude it from obtaining the IME to consider the claim. The court likewise rejected Reliance Standard’s arguments, explaining the insurance policy only required exhaustion of administrative remedies prior to an arbitration of a claim. The court accordingly remanded the matter back to Reliance Standard with instructions that Rogers undergo the IME, by a doctor agreeable to both parties. All in all, the process ended up consuming another year, just to have the case go back to Reliance Standard again, though far better than possibly having the case dismissed for failure to comply with the insurer’s request.