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Can Insurance Companies Hire Biased Doctors?

When an individual suffers injuries at work, he or she will likely qualify for workers’ compensation benefits or an insurance settlement to cover his or her damages, including medical expenses and lost wages. However, securing compensation for a workplace injury is far more difficult than simply filing an insurance claim and waiting for a check. Insurance companies want to ensure that a claim is valid and falls within the scope of the policy in question before paying out on the claim. This usually entails an investigation which may include examination by a doctor chosen by the insurer.

The problem is a growing concern over the number of doctors siding with insurance companies and disputing patients’ claims. When an employee files a workers’ compensation claim, he or she must see a doctor from a list provided by the employer’s workers’ compensation insurance company. If the injured employee requires emergency treatment, then he or she may visit any available doctor, but the patient must return to one of the insurer’s approved doctors once the emergency situation stabilizes.

Independent Medical Exams After Workplace Injuries

After an employee sustains a work-related injury, the employer’s insurance carrier will likely request that the employee submit to an independent medical examination. An insurer will likely deny a claim if the claimant refuses to undergo such an examination. Workers’ compensation insurance carriers want to find any medical reason possible to prove that a claimant is ready to return to work, which results in less benefits for the injured claimant.

An insurance company may demand an independent medical examination if the insurer disagrees with the medical opinion of the claimant’s attending physician, or if the claim is taking too long and getting too expensive to handle. Additionally, an insurer may demand an independent medical examination if it requires evidence to resolve a dispute in a claim or to limit a claimant’s available benefits. If a claimant’s initial treating physician reports any type of permanent disability, the claimant should expect the workers’ compensation insurance carrier to demand an independent medical examination.

Unfortunately for workers’ compensation claimants, most insurance company-approved doctors are “fringe” doctors that primarily function as general practitioners. These doctors generally avoid expensive imaging tests and most often resort to medication to treat injured employees. Workers’ compensation doctors generally make more money the more referrals they receive from insurance companies, so it is in their financial best interests to side with the insurer over a claimant. If a doctor approves too many claims, the insurance company may stop referring claimants to the doctor.

Insurance Bad Faith and Medical Malpractice

“Independent Medical Examination” is something of a misnomer as well, due to the fact that most workers’ compensation insurance company-approved doctors receive payment from those insurance companies for performing examinations. This can create a difficult situation for an injured employee; refusing an independent medical examination can lead to a flat claim denial, whereas an independent medical examiner has little to no incentive to diagnose in favor of the claimant.

If an insurance company’s approved doctor does not provide a claimant with an acceptable diagnosis, the claimant has the right to a second opinion. However, the second opinion must come from another doctor on the insurance company’s approved list. It’s possible that the second doctor simply parrots the diagnosis from the first doctor without investigating further.

Any injured employee who encounters such a situation should speak with an experienced workers’ compensation attorney as soon as possible to determine possible options for legal recourse. If an attorney uncovers any type of quid-pro-quo behaviors between the insurance carrier and an independent medical examination provider, the injured worker may have grounds for an insurance bad faith lawsuit or other legal remedies.