Who Should Prepare Your IME Referral Questions? is a web site version of a newsletter for disability insurers.It was authored by Leonard Grossman, Ph.D., a psychologist and diplomate of The American Board of Forensic Examiners.
Despite being 10 pages long, your psychiatric IME report fails to adequately address your
referral questions.
Utilizing a top notch forensic psychiatric IME examiner is no guarantee you'll get a quality report. If you or your department have been writing your own referral questions, or have been using some type of generic "checklist" form, it may be time to reconsider your approach.
The reality is, no matter how much IME experience your examiner has, he or she probably knows as much about insurance issues as you do about clinical psychiatry. Your IME referral questions may be clear to you, but how will they be interpreted and responded to by the examiner?
Avoiding Speculation and the Appearance of Bias
As a general rule, the more generic your referral questions are, the greater the risk of inappropriate speculation or commentary. For example, a question asks: "What are this claimant's psychiatric limitations, and what are the objective findings supporting these limitations?" While this sounds like a fairly straightforward question, it fails to specify the type of limitations you are most interested in. Even though material on policy conditions (own occupation, any occupation, etc.) may have been included elsewhere within the records, there's no guarantee it will be noticed or properly understood and applied by the examiner.
And even more serious problem can occur when insurer questions are unintentionally framed in a prejudicial or argumentative manner, such as: "Can total disability be supported in light of the fact that Mr. Smith was recently married and honeymooned in Italy for two weeks?"
The bottom line is, once a report is submitted, it goes into the official record and can be subpoenaed in any future litigation proceedings. While you can always ask for an addendum, you're still stuck with the original report. As an ounce of prevention is worth a pound of cures, every effort should be made to make your IME referral questions as objective, professional, and legally sound as humanly possible.
Have your IME questions reviewed by a licensed mental health professional who can translate them into appropriate clinical terminology.
Ideally, your referral questions should be reviewed by a licensed psychiatrist or psychologist with both disability consulting and insurance experience. Consultants should also be familiar with the case history and review any associated medical records or reports deemed important.
In LTD cases, the most critical question which needs to be translated from insurance to clinical terminology centers around the severity and scope of the claimant's present psychiatric symptomotology. Based on many years of experience, I believe examiners should never be asked to rule directly on a claimant's disability status. Instead, we should ask: "Based on your review of records and clinical diagnostic impression, what are Mr. Smith's psychiatric abilities and limitations as they relate to his ability to meet the duties and responsibilities required by his usual occupational work?"
Expanding this question, we can then ask the examiner to detail any objective and subjective findings which support claimant limitations and indicate their potential work-related impact. Phrasing questions in this manner avoids the need for examiners to interpret complicated disability policy language.
It's preferable to avoid providing such language because it places examiners in the inappropriate and uncomfortable position of ruling on insurance, rather than clinical, issues. Furnishing policy language also opens the door for accusations of examiner bias if your case goes to litigation.
Framing Questions on Malingering and Secondary Gain
In cases with large benefit reserves, it may be appropriate to ask the examiner to evaluate issues of secondary gain and malingering. However, it is essential that such questions be phrased exclusively in clinical terms, and be expressed without the appearance of bias or prejudice.
In terms of the malingering assessment itself, this is best accomplished via examiner-selected psychological and/or neuropsychological testing. That being said, it is my professional opinion that, to avoid any appearance of bias or bad faith, the word malingering be entirely omitted from your referral questions letter. Instead, we can express the need for this type of information in a more neutral and affirmative manner: "Please administer any psychological or neuropsychological tests deemed clinically appropriate to validate the pattern, scope, and severity of symptom manifestation."
For More Information
Needless to say, there's a lot more to be said regarding what constitutes an optimal IME referral questions letter. If you're interested in learning more about how The Forest Hills IPA can work with you to improve your own IME process, or have a case you need immediate assistance with, please contact us at (718) 786-1328. You may also wish to check out our new special on-line guide, The ABCs of Managing Psychiatric Disability Cases.
Sincerely,
Leonard Grossman Ph.D.,
President, The Forest Hills IPA Inc.
Diplomate, The American Board of Forensic Examiners
January 2004 Newsletter
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