Do You Have to Attend an Independent Medical Examination for an LTD Claim in Ontario?

If your long-term disability insurer asks you to attend an independent medical examination, you should not ignore the request. Most LTD policies allow insurers to request reasonable medical examinations as part of the claim process.

However, an IME can also be a signal that the insurance company is reassessing your entitlement, questioning your restrictions or building the evidence it may later use to deny or terminate benefits. If the insurer relies on the IME to cut off or refuse LTD benefits, it could be necessary to start a lawsuit for unpaid disability benefits. The attendance issue and the denial issue are separate: you may need to attend a reasonable IME, but you may also need to commence a legal claim if the insurer later uses the report to deny a disability claim.

Independent medical examinations, sometimes called an independent medical assessment, can sound routine. The insurance company might describe it as an update, a review or a way to "clarify" your medical status. Sometimes that is true. However, the assessment can sometimes become a major piece of evidence used to challenge your claim.

The word “independent” can also be misleading. The assessor should provide an objective medical opinion, but the examination is usually arranged and paid for by the insurance company. The the medical assessor will send the report to the insurer and may be used to decide whether your LTD benefits continue, stop or remain denied.

Our Ontario long-term disability lawyers can help if an Independent Medical Examination is utilized to deny your claim.

What Is an Independent Medical Examination in an LTD Claim?

An independent medical examination is a medical or functional assessment arranged by the disability insurer. The assessor is not there to treat you but instead to provide the insurance company with another opinion about your diagnosis, restrictions, limitations, prognosis, treatment or ability to work.

In LTD cases, IMEs can be arranged with a physician, psychiatrist, psychologist, neuropsychologist, physiatrist, occupational therapist, functional capacity evaluator or another specialist. The type of assessment chosen by the insurer usually depends on the medical issues in dispute.

An IME is different from treatment. The assessor is usually not there to treat you, prescribe care or manage your recovery. The assessor’s role is usually to examine you, review records and prepare a report for the insurance company.

Why Would an LTD Insurer Request an IME?

An insurer may request an IME because it wants more information before deciding whether to approve, continue, deny or terminate LTD benefits.

The request could come after a claim is submitted, after benefits have been paid for a period of time, near a change in the disability definition, after new medical information is received, or if the insurance company believes there is a gap between your reported limitations and the medical records.

The timing of the request can be important. An IME shortly before a benefit termination, change-of-definition review or appeal decision may become in important component of the insurer’s decision.

Do You Have to Attend the IME?

In most LTD claims, the answer will be yes, if the policy provides the insurance company with the right to request a reasonable medical examination.

The precise answer is dependent upon the actual policy wording, the type of assessment that is requested, the reason for the request and the circumstances of the case.

Some LTD plan documents expressly allow the insurance company to request additional medical information or arrange medical examinations. For example, the federal public service Disability Insurance Plan refers to the insurer’s right to request additional medical information or arrange medical examinations as often as reasonably required.

That does not mean every request is automatically reasonable. The assessment should be logically connected to the disability claim. The timing, location, type of assessor, medical issues, claimant’s condition and prior assessments may all be relevant.

The main point is this: a claimant should not simply ignore the request or refuse because the assessment feels unfair. A refusal can create a separate problem for the case.

Can Refusing an IME Hurt Your LTD Claim?

Yes. Refusing to attend an IME can hurt an LTD claim if the policy provides the insurance company with the right to request the examination and the request is reasonable.

The insurer may argue that it cannot properly assess the claim without the examination. It could suspend benefits, deny benefits, terminate benefits or rely on the refusal as evidence that the claimant has not cooperated with the claim process.

That does not mean every concern should be ignored. There may be legitimate issues involving travel distance, disability-related accommodations, the type of specialist, the scope of the assessment, language barriers, the length of testing, psychological distress, medical risk or repeated assessments.

However, claimants should avoid responding in a manner which enables a legitimate concern to transform into an avoidable non-cooperation argument.

What Types of IMEs Are Used in LTD Claims?

The type of IME that the insurance company will request depends on the condition and the issues in dispute. For example, a physical medicine assessment could be utilized for chronic pain, orthopedic injuries, neurological issues, spinal conditions or other physical limitations. A psychiatric or psychological assessment may be used for depression, anxiety, PTSD or other mental health conditions. A neuropsychological assessment may be used where memory, attention, processing speed, executive function or brain injury symptoms are disputed.

An occupational therapy assessment or functional capacity evaluation might focus more directly on physical tolerances, activity levels and work-related function. Some assessments review transferable skills or vocational capacity, especially where the insurer is considering whether the claimant can perform other suitable work.

How Can the IME Report Be Used Against You?

An IME report can be used by the insurance company to support a denial, termination or refusal to reinstate LTD benefits. The assessor could conclude that you are able to return to your own occupation, perform modified duties, increase activity, pursue a gradual return to work or perform another suitable occupation.

The insurer may rely on that opinion even if your treating doctors disagree.

The report could comment on symptom consistency, effort, examination findings, test results, medication, treatment, prognosis or whether your reported limitations match the assessor’s observations.

Disputes between insureds and their insurance companies can arise when a short assessment is treated as more important than months or years of treatment records. The IME may not capture symptom flares, post-activity decline, fatigue, pain behaviour after the appointment, failed work attempts or the difference between completing a task once and sustaining work reliably.

If the report is later used to deny or terminate benefits, the dispute usually becomes more serious. At that point, the issue is often not whether the claimant can write a better explanation to the insurer. The issue is whether the insurer’s denial should be challenged through a lawsuit for unpaid LTD benefits.

What If the IME Doctor Disagrees With Your Treating Doctors?

Treating doctors have longer histories with the claimants which may enable them to understand symptom patterns, treatment response, medication effects and functional decline over time. The IME assessor usually have only a single appointment and a selected record package.

On the other hand, an insurance company can argue that the IME assessor gave a more detailed opinion about work capacity. That is why treating evidence may need to address the issues raised in the IME report.

A strong legal case could focus on why the IME opinion is incomplete, why it misunderstood the job duties, why it failed to account for symptom variability, why it overlooked treatment history or why its conclusions do not match the full medical record.

Can an IME Lead to an LTD Denial or Termination?

Yes. An IME can lead to an LTD denial or termination if the insurance company relies on the report to say disability is not supported. The insurer may use the report to argue that you can return to work, that your restrictions are less severe than reported, that treatment should improve function, that your condition is not totally disabling, or that you do not meet the policy definition after the change from own occupation to any suitable occupation.

The next step depends on the denial letter, the policy, the limitation period, the medical record and the strength of the IME report. If benefits are denied or terminated after an IME, a lawsuit may be required to force the insurer to defend its decision and to pursue unpaid disability benefits.

Our guide to long-term disability claims and denials in Ontario explains how LTD disputes usually move from insurer denial to legal action.

Should You File an Internal Appeal After an IME-Based Denial?

Many LTD denial letters will refer to an internal appeal. An internal appeal may be available, but it is not always the best route.

Internal appeals send the dispute back to the insurance company that denied or terminated the claim. In some cases, additional medical evidence could change the insurer’s position. However, in many cases, especially where the insurer has already relied on an IME report, the internal appeal may simply delay the claim.

Claimants should be careful about spending months in repeated appeals while the deadline for a lawsuit continues to run.

If benefits have been denied or terminated after an IME, the more meaningful step will often be to commence a lawsuit rather than attempting to persuade the insurer through another internal review.

How Do IMEs Compare With Paper Reviews?

An IME involves an examination or assessment of the claimant. A paper review usually involves a medical consultant reviewing records without seeing the claimant.

A paper review may focus on chart gaps, missing restrictions or the absence of objective findings. An IME may add examination findings, testing, observations and the assessor’s opinion about function.

Neither type of review should be accepted uncritically. The question is whether the opinion fairly considers the medical evidence, the claimant’s condition, the job demands and the policy definition of disability.

For more detail, read our guide to paper reviews in long-term disability claims.

Can Surveillance Be Used Together With an IME?

Yes. Surveillance and IMEs may be used together in some LTD claims. An insurance companies might arrange surveillance before an IME and then provide the video or activity summary to the assessor. The assessor could be asked whether the observed activity is consistent with the claimant’s reported limitations.

This can be risky for claimants if the medical evidence does not explain variability, flares or the difference between occasional activity and reliable work. A video clip of shopping, driving or attending an appointment may not show pain afterward, fatigue, rest periods or symptom worsening later in the day.

Surveillance does not always prove work capacity, but it can influence how an IME assessor interprets the claim.

For more detail, read our guide to long-term disability surveillance in Ontario.

IME Requests From Manulife, Sun Life, Canada Life, RBC or Desjardins

IME requests can arise in LTD claims administered by Manulife, Sun Life, Canada Life, RBC Insurance and Desjardins.

The insurer’s name does not decide whether the IME request is reasonable or whether the report should be accepted. The key issues are the policy wording, the reason for the assessment, the claimant’s medical condition, the work-capacity dispute and how the report is used.

A claimant should not ignore an IME request simply because it comes from the insurer. But if the insurer later relies on the IME to deny or terminate benefits, the dispute may need to be challenged through a legal claim.

Frequently Asked Questions About LTD IMEs in Ontario

What is an IME in a long-term disability claim?

An IME is a medical or functional assessment arranged by the disability insurer. The assessor usually examines the claimant, reviews records and prepares a report for the insurer.

Do I have to attend an IME for my LTD claim?

Often, yes, if the LTD policy gives the insurer the right to request a reasonable medical examination. The answer depends on the policy wording, the type of assessment and the circumstances of the claim.

Can my LTD benefits be stopped if I refuse an IME?

They can be. If the insurer has a policy-based right to request the examination and the request is reasonable, refusal may lead to suspended, denied or terminated benefits.

Is an IME doctor really independent?

The assessor should provide an objective opinion, but the examination is usually arranged and paid for by the insurer. The report is usually sent to the insurer and may be used in the claim decision.

What should I bring to an LTD IME?

Follow the appointment instructions. You may be asked to bring identification, medication information, assistive devices, completed forms or relevant medical information. Do not assume the assessor has every record unless the request letter says so.

Can I record an IME?

Do not record an IME without getting legal advice first. Recording rules, consent issues, assessor policies and insurer instructions can create complications.

What if the IME report is wrong?

If the IME report is later used to deny or terminate benefits, the report should be reviewed against the treating medical evidence, the policy definition and the job duties. In many cases, the stronger step is not another generic appeal, but a legal claim for unpaid LTD benefits.

Can an IME be used with surveillance?

Yes. In some claims, surveillance may be provided to the IME assessor. The insurer may ask whether the observed activity is consistent with the claimant’s reported restrictions and limitations.

Can an IME lead to an LTD denial?

Yes. An insurer may rely on an IME report to deny, terminate or refuse to reinstate benefits. The report should be reviewed carefully if it becomes part of the insurer’s decision.

Should I appeal or sue after an IME-based LTD denial?

It depends on the policy, denial letter, limitation period, medical record and strength of the IME report. Internal appeals may be available, but they are not always the best route. If benefits have been denied or terminated, a lawsuit may be needed to pursue unpaid LTD benefits.

Speak With an Ontario Long-Term Disability Lawyer

An independent medical examination can be an important turning point in an LTD claim. While the request is likely reasonable, the report could become evidence used to challenge your disability, question your restrictions or terminate benefits.

At Foster Injury Law, our Ontario LTD lawyers assist people across Ontario with denied, terminated and disputed long-term disability claims, including claims involving IMEs, paper reviews and surveillance.

Contact Foster Injury Law for a free consultation if your LTD insurer has requested an independent medical examination or has relied on an IME report to deny or terminate your benefits.

Author: Lane Foster