INDEPENDENT MEDICAL EXAMINATION (I.M.E.) / FUNCTIONAL ABILITIES EVALUATION (F.A.E.)

Disability insurance companies are entitled to send you to a doctor of their choice. This is called an Independent Medical Examination (I.M.E.). Sometimes you can be sent for a Functional Abilities Evaluation (F.A.E.) or Rehabilitation Specialist in order to determine whether you are able to work.

Although it is called an IME, it is far from "independent” as the report is paid for by the insurance company. You can of course get an 'independent' evaluation of your own with a doctor or specialist with the same credentials as the one that you were sent to by the insurance company. Clearly, for an evaluation to be "independent" an unbiased evaluation can only be performed by someone who represents neither side.

When you are sent for an IME by the insurance company, unless you have evidence that the doctor or evaluator is biased, you must attend the assessment. This is part of the agreement in the insurance policy. You can ask the doctor evaluating you or the insurance company to send a copy of the report to your attending physician and you then can in turn get a copy of it. Once you have a copy, you can determine whether or not you should get an IME or FAE of your own by getting a referral from your doctor.

Once you have attended the IME or FAE, it is important you write down what transpired at the examination. The length of the interview, what kind of examination was given and any other information that you can remember. You may not need this information but it is best to be prepared in case you do

If you are sent for rehabilitation by the insurance company in anticipation of returning you to work, make sure that your own doctor is aware what functions you will be performing at rehab. See your doctor on a regular basis and keep him informed how you are managing so that the doctor can report your progress or deterioration and can stop it if is hazardous to your health.

IMPORTANT NOTE: If you have to attend any of these evaluations, be sure to also record what transpired and how you feel before and after this testing. Keep a log for about a week or longer if you are experiencing bad reactions to the testing and make sure to report to your doctor so that there is a record of it. As the evaluation will be tiring, it is best to have someone drive you to and from the evaluation.

When you are attending for an evaluation or assessment, the interrogator may be harsh or sometimes even hostile or throw speedy questions at you to intimidate you. If that is the case, keep your cool and stay calm. Do not reply if you are not certain that you understood the question. Ask the individual to repeat the question and listen to make sure you understand it. Very often you may need to go over the question in your mind before you can absorb the information. Take the time and do that.

When asked to explain your symptoms, be as specific as possible. Remember that the individual does not know you and can't fill in the blanks. Use examples as much as possible i.e. after I brush my teeth, I have to lie down for 15 minutes and rest. When I try to exercise, I feel faint etc. Painting a picture in the questioner’s mind gives the individual a better understanding about what you are going through. Be sure to point out the unpredictability from day-to-day as to how you are feeling and what you can do.

HOW DISABILITY A DISABILITY PENSION IS EVALUATED:

You can be sent for an IME or FAE any time once you have applied for a disability pension. In the first one or two years (depending upon the policy your employer has with the insurance company) you have to prove that you cannot do YOUR job. Once the one or two years are over, you are then looking at Long Term Disability (LTD), and you must prove that you cannot do ANY job.

WHEN TALKING TO YOUR INSURANCE REPRESENTATIVE:

When you speak with someone at the insurance company regarding your case, be sure to get the name of the individual you are speaking to and what the individual's position is. Once you get off the phone, keep a record of the conversation and who you spoke to, the date of the conversation, the length, details of the discussion and the outcome. If necessary, if some agreement has been made by phone, follow it up for a letter detailing the conversation and the outcome, including whom you spoke with. If you do not hear back from them, then you can presume they agree with what you wrote. If not, it puts them into a position of replying to you in writing to deny or amend the agreement. A lot of misunderstandings can be avoided by accurately keeping records of important facts. This will help you if you ever need to see a lawyer or to discuss any follow-ups with the insurance representative.

What also occurs is that you get used to dealing with a certain insurance representative and you have become familiar and comfortable with that person and then the representative gets changed. This results in delays and the new individual having to get acquainted with your file. Some may read the whole file and is up to date as to what has been transpiring while others may not bother or simply read only a small part of the file. This too is a normal occurrence. As much as that will frustrate you, expect that this may happen and keep that in mind when you need to start with someone new.

No matter how frustrated or angry you may feel, it is better for you to cut the call short and find some excuse to get off the phone than lose your cool. Tell the person to call you back at a convenient time or say you will call back at a certain time. The representative has been trained to do what they do and losing your temper or your patience is not going to help your case and indicates to the representative that the claim is getting to you and maybe you will get so upset, you will drop your claim.

Another way that you may find yourself getting upset is to either get a disability pension denial letter from your insurance company around a holiday or a notice to report for an IME or FAE around that time. Naturally you will be upset because of the timing. Remember that this is intentional and the insurance company very well knows what kind of effect this may have on you. It will not lessen the stress but if you expect the unexpected then you are more capable of dealing with your reactions.

WHEN TO SEE A LAWYER:

As long as the insurance company keeps paying you your disability pension, there is no need to see a lawyer. However, once you get a letter denying your disability claim, it is time to see a lawyer. In the denial letter, it will outline why the insurance company is refusing your claim. Usually a lack of medical evidence or the IME assessor expressing that you are not disabled and able to work.

Be sure the lawyer is experienced in insurance law and disability claims. If the lawyer is also experienced with your illness, that is another valuable asset. With ME/CFS and FMS case related illnesses, there are still some lawyers who are not acquainted with the disabling nature of the illness so be sure that the lawyer is comfortable representing you**. Sometimes all that is needed to reinstate your claim is for the lawyer to write a letter to the insurance company but in most cases your lawyer may be forced to sue. This may take some time but many cases are settled much before trial.

You may also want to check if there is Legal Aid available in your province or if there are any disability organizations that are able to help you.

**The National ME/FM Action Network keeps a National Lawyers' Roster (Canada) and the lawyers on that Roster are experienced with ME/CFS and FMS and related illnesses. Their initial consultation with you is free.

FILING A DISABILITY CLAIM:

It is not unusual for an insurance company to deny your claim and making it difficult for you to get the disability pension you are entitled to. Don't let that deter you. The insurance company is a business reporting to shareholders and therefore each and every claim puts a dent into its profits. As your claim goes up importance in the insurance hierarchy, new eyes with more medical knowledge will look at your claim.

Another way a claim can be deterred is when an employer's representative in charge of dealing with you and the insurance company discourages you from filing a claim. That is not the representative's job. The employer wants to keep his insurance rates as low as possible and of course too many claims would push the rates upwards. Some insurance companies may also give rebates to employers who have low claims.

The insurance company’s goal is to keep their costs to a minimum and therefore to have as few people receiving disability benefits as possible. To this end they very often choose doctors whom they can rely on to give them a report that expresses the opinion that the patient is not disabled, even when there is overwhelming evidence that the patient is. In addition, Dr. Arnold Voth indicated that the IME doctors are often paid ten times or more than the usual payment for a medical report. The insurance companies will not pay these kind of fees unless it is clear that they will receive a report that benefits them.

WHAT NOT TO DO:

If you are off for a length of time, your employer may put pressure on you to quit your job or return to work. If your doctor determines that you are not able to do so, know then that there are laws protecting you and you are covered by the Declaration of Human Rights and cannot be discriminated against because you are disabled. Unless it is a financial hardship to the employer, the employer has to accommodate you if you decide you want to return to work in some other position or lesser responsibility. Do not sign any documents, without getting a proper legal opinion first.

WHAT OPTIONS YOU HAVE FOR FINANCIAL ASSISTANCE:

Before you apply for a disability pension from the insurance company, if you have been working, you can apply for Employment Insurance (EI) which will pay you for 15 weeks disability. For some of you this may be enough and you are able to return to work. Those who cannot must then see their employer to apply for a disability pension from the insurance company.

If you have paid into the Canada Pension Plan, now is the time to also look to apply for a CPP Disability Pension (CPP-D). Elsewhere on our website, you will find details regarding that. The insurance company usually will also ask you to apply for same as it reduces its monthly disability pension to you by the amount of CPP-D payments.

If you have not paid into CPP or haven't paid long enough, you need to look into a provincial disability plan. This is done through the Social Assistance Program, also known as Welfare. Welfare payments are for those who are able to work but are unemployed while those who are unable to work due to illness must apply under the disability section.

You may also be eligible for a Disability Tax Credit which you also have to apply for from Revenue Canada and needs your doctor's signature. Once you qualify, this will help at Income Tax time.

Another good place to check for what avenues are open to you for financial assistance due to illness is to check with your provincial government.

SURVEILLANCE:

Do not be alarmed if you suspect that your insurance company is surveilling you. That may happen and you must always keep that in mind. For an insurance surveiller to report your activities need not frighten you, unless you are doing something that you reported you were unable to do. For instance, if you reported that you could not lift anything and you are recorded lifting a heavy object, then it would be very difficult for you to explain why you were able to do so. Another instance would be if you reported that you were unable to vacuum and someone caught you doing just that, then that too would be hard to explain away. It is vital that you be honest and do not exaggerate what you can and cannot do.

FINAL REMARKS:

It is important for you to remember that you are not alone in what you are going through. How the insurance company is treating you is no different from how other people are being treated. Determination and persistence will get you your disability pension even if it will takes some time. In other words, do not take no for an answer if you are entitled to a disability pension. Just because the insurance company states you do not qualify does not mean that you have to take it as fact. Take whatever steps necessary you need to do the get what you deserve. Above all else, don't give up.