Insurance Adjuster Requests for Medical Records and Exams

In evaluating your injury claim, the adjuster will request your medical records, and could ask for an IME.

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As your injury claim proceeds, the insurance adjuster will want to get his or her hands on all documentation surrounding your injuries and your medical treatment, and in some situations, you might be asked to undergo an "independent medical examination" (IME). In this article, we'll offer some pointers on dealing with these kinds of requests.

When the Insurance Adjuster Requests Your Medical Records

Although you will have sent copies of all your relevant medical records along with your personal injury 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.

(For information on obtaining your own medical records, check out Getting Your Medical Records: Information on Rights, Procedures, and Denials.) 

Do not sign your rights away. Never sign an agreement authorizing an adjuster to directly obtain any of your medical records, and never give the adjuster verbal permission to obtain them. ­Always obtain records yourself. Review them to make sure they pertain only to your claim and do not unnecessarily reveal the rest of your private medical history. Then provide the adjuster with those records that pertain directly to accident injuries.

When the Adjuster Requests a 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 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.

When the Adjuster Requests a 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.

For an in-depth guide to getting the best resolution to your injury-related insurance claim or lawsuit, get How to Win Your Personal Injury Claim, by Joseph L. Matthews (Nolo).

by: , J.D.

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