What Happens at an Independent Medical Examination in an Ontario Personal Injury Claim?

An independent medical examination, or IME, in an Ontario personal injury claim is an assessment arranged by an auto insurer or defence lawyer to obtain medical evidence about an injured person’s condition. An IME can affect accident benefits, a catastrophic impairment application or a lawsuit. Do not ignore an IME request; obtain legal advice before attending or refusing.

An Ontario personal injury lawyer can review the request, explain whether it relates to accident benefits or a lawsuit and advise you before the assessment takes place.

Do I Have to Attend an Independent Medical Examination in Ontario?

Do not refuse or miss an IME without first obtaining legal advice. In Ontario accident benefits claims, the insurance company can require an injured person to attend and participate in a reasonable section 44 examination where the request complies with the Schedule. Failure to attend can affect the payment of benefits connected to the examination request.

In a lawsuit, a defence medical examination can take place by written agreement or after a court order under Rule 33 of Ontario’s Rules of Civil Procedure. Ignoring a properly arranged or court-ordered examination can create serious problems in the lawsuit.

That does not mean every request should simply be accepted without review. Questions can arise about the notice given, the reason for the examination, the professional selected, whether another assessment is actually necessary, travel arrangements or accommodations required because of the injury.

Why Is It Called an Independent Medical Examination or IME?

The term “independent medical examination” is commonly used by insurance companies, lawyers and medical assessors. It can give the impression that the appointment is simply another neutral medical visit.

However, the examiner has been hired by an insurance companyto prepare medical opinion. In an accident benefits claim, the insurer has arranged the assessment to obtain an opinion about a benefit being claimed. In a lawsuit, the examination is arranged for the defence so it can obtain its own medical evidence about the injuries being alleged.

The examiner is expected to provide a professional medical opinion. But the report is prepared for use in an insurance or litigation process. It can be relied on to challenge treatment, disability, the extent of an injury or the need for future support.

That is why it matters whether the appointment is an insurer’s examination under the accident benefits system or a defence medical examination in a lawsuit.

What Is a Section 44 Insurer’s Examination in an Ontario Accident Benefits Claim?

After a motor vehicle accident, an injured person can apply for Ontario accident benefits regardless of who caused the collision. Fault does not prevent an accident benefits claim. An insurance examination can become important in serious Ontario car accident claims where treatment, income loss, attendant care or catastrophic impairment is disputed.

A section 44 insurer’s examination, sometimes called an insurer examination or an IME, is an assessment arranged by an auto insurer to obtain medical, functional or vocational evidence about a benefit being claimed.

For a broader explanation of available benefits, insurer disputes and claims under the SABS, see our page about accident benefits in Ontario.

Section 44 of the Statutory Accident Benefits Schedule allows the insurer to require an examination to help decide whether an injured person is, or continues to be, entitled to a benefit being claimed.

An insurer’s examination could arise if the insurer is considering a treatment and assessment plan, medical or rehabilitation benefits, attendant care benefits, income replacement or non-earner benefits where available under the applicable policy and claimed, the continuation of ongoing benefits, or whether the injured person has sustained a catastrophic impairment.

The insurer chooses the assessor or assessors. Depending on the issue, the assessment could be conducted by a physician, psychologist, occupational therapist, neuropsychologist or another regulated health professional. Where employment capacity or vocational rehabilitation is in issue, vocational evidence can also become relevant.

What Notice Must an Insurer Provide Before a Section 44 Examination?

The insurance company is required to arrange and pay for the examination. It must also give written notice explaining why the examination is necessary.

The notice must identify the medical and any other reasons for the examination, whether you must personally attend, the name of the person or people conducting the assessment, their regulated health profession and stated specialization where applicable, and the date, time and location where attendance is required.

Where you must attend in person, the insurer must generally provide notice at least five business days before the examination unless you agree otherwise.

Some section 44 examinations are completed as paper reviews without the injured person attending. If an assessor later decides personal attendance is required, further notice must be provided before the in-person assessment takes place.

A notice of insurer’s examination should be read carefully. It should be clear what benefit is being assessed and why the insurer says an examination is required.

What Happens During an Insurer’s Examination?

The specific assessment that will occur depends on the claimed injury and the benefit under review.

An orthopaedic examination can address pain, strength, mobility, surgical history and physical restrictions. A psychological or psychiatric assessment can deal with trauma symptoms, mood, concentration, sleep, daily functioning and the ability to work. A neurological or neuropsychological assessment can arise where a person reports cognitive changes or has suffered a traumatic brain injury.

The assessor usually asks questions about the collision, symptoms, medical history, treatment, work, medication and daily activities. The assessor can also review medical records, imaging, treatment reports and other documents provided for the assessment.

Answer questions honestly and carefully. Do not exaggerate symptoms or minimize genuine difficulties simply because you are uncomfortable describing them. If you do not remember a date or detail, state that you do not remember rather than guessing.

If testing or movement causes increased symptoms, say so. Being able to perform an activity with substantial pain, dizziness, fatigue or difficulty is not the same as being able to perform it normally.

The examiner is not there to treat you or replace your treating medical team. The appointment is taking place so a report can be provided for use in the claim.

How Can an Insurer’s Examination Affect a Catastrophic Impairment Claim?

In serious motor vehicle injury cases, Section 44 examinations are usually requested after an application for a catastrophic impairment determination.

Catastrophic impairment designation are critical for someone who sustained life-changing injuries. It significantly affects access to medical, rehabilitation and attendant care benefits under Ontario’s accident benefits system.

If a catastrophic impairment is claimed, the insurance company can arrange assessments directed at the applicable criteria. Depending on the injuries, that can involve assessments addressing brain injury, spinal cord injury, severe physical impairment, psychiatric impairment, functional limitation or a combination of impairments.

The insurer must provide its decision and medical reasons after receiving the examination report. If the insurer rejects the catastrophic impairment designation, the decision can become the subject of a significant dispute requiring detailed medical and functional evidence.

A catastrophic impairment claim should not be treated as simply a disagreement between two doctors. The designation can shape the injured person’s access to treatment, rehabilitation, attendant care and long-term support.

For more information about claims involving permanent and life-changing injuries, read about catastrophic injury claims in Ontario.

Can an Insurer Deny Benefits After an Insurer’s Examination?

Yes. An insurance company can rely on a section 44 examination report when deciding whether to approve, deny or stop paying a claimed accident benefit, including treatment, income replacement or attendant care benefits.

That decision is not necessarily correct or final. Where benefits have been denied after an insurer’s examination, the denial can be challenged using treatment records, specialist evidence, functional evidence and, where required, a proceeding before the Licence Appeal Tribunal.

What Is a Defence Medical Examination in an Ontario Personal Injury Lawsuit?

A defence medical examination is separate from a section 44 insurer’s examination.

Where an injured person has started a lawsuit and their physical or mental condition is in issue, the defendant can seek a medical examination under Rule 33 of Ontario’s Rules of Civil Procedure. In most personal injury lawsuits, the request is made through the lawyer appointed by the defendant’s insurer.

The defence could seek an examination if the injured person claims ongoing pain, impaired mobility, cognitive symptoms, psychological injury, loss of income, future care needs or another continuing effect of the injury.

A defence medical examination can proceed by written agreement. Where the parties disagree about the examination, its scope or the person conducting it, the issue can be brought before the court.

Serious injury lawsuits can involve more than one proposed defence examination where different injuries or functional issues are genuinely in dispute. Whether another examination is appropriate depends on the circumstances of the case.

Can Someone Come With Me to an IME?

For a defence medical examination in a lawsuit, Rule 33 generally provides that only the person being examined, the examining health practitioner and any required assistants are present, unless the court orders otherwise.

An accident benefits insurer’s examination is governed by the Statutory Accident Benefits Schedule, not Rule 33. Where an injured person requires support or accommodation because of a brain injury, communication difficulty, physical impairment or another serious limitation, that issue should be raised before the appointment.

Do not assume a support person can attend. Do not assume support will be refused either. Address the issue in advance so that necessary arrangements can be considered properly.

Will I Receive the IME Report?

In an accident benefits claim, the report should be reviewed in the context of the specific benefit the insurer is deciding. For example, the Schedule contains report-delivery requirements where an insurer examination is obtained concerning treatment plans, certain ongoing benefits, attendant care or a catastrophic impairment application. In a catastrophic impairment claim, the insurer must provide the examination report and advise whether it accepts or rejects the catastrophic impairment designation, together with its reasons.

In an Ontario injury lawsuit, a medical report prepared following a Rule 33 examination is provided through the litigation process.

When an insurer or defence medical report is received, it should be reviewed carefully. Reports can contain incomplete histories, misunderstandings about symptoms or conclusions that are inconsistent with the treatment record and the day-to-day reality of the injury.

Where a report understates the impact of an injury, the answer is usually evidence: treating records, specialist opinions, functional assessments, employment evidence and testimony from people who understand how the injury has changed the person’s life.

How Should I Prepare for an Independent Medical Examination?

Preparing for an IME does not mean memorizing answers or trying to influence the assessment. It means understanding the appointment and attending it carefully.

Before the assessment, make sure you know whether it relates to accident benefits or a lawsuit, who requested it, who will conduct it, what issue or benefit is being assessed and whether accommodation or transportation issues need to be addressed beforehand.

During the course of the examination, describe symptoms and restrictions accurately. If you cannot remember something, say so. If you can perform an activity only with pain or difficulty, that is different from being able to do it normally. If a task causes symptoms, explain what happened.

After the assessment, make a note of how long it lasted, the tests or activities performed and any symptoms that occurred during or after the appointment. That information can matter if the report later describes the assessment in a way that does not match your experience.

Can an Insurer or Defendant Request More Than One Examination?

Yes, although there are limits. Under section 44, an accident benefits insurer can require examinations only as often as is reasonably necessary to decide entitlement to a claimed benefit. Serious claims can involve different benefit disputes or a later catastrophic impairment application, but repeated examinations are not automatically justified simply because the insurer wants more opinions.

In a lawsuit, the defence can seek a further medical examination where appropriate. A serious injury case involving physical, cognitive and psychological impairments can involve different areas of expert evidence. The number and scope of examinations must still be fair and connected to the issues genuinely in dispute.

When Should I Speak With a Lawyer About an IME?

It can be a good idea to obtain advice promptly after receiving notice of an insurer’s examination or defence medical examination, especially where the injury is serious or important benefits are already in dispute.

Advice is especially important where a catastrophic impairment application is being assessed, treatment or attendant care has been disputed, an insurer is threatening to stop benefits, a defence lawyer has requested an examination in a lawsuit, repeated assessments are being arranged or the injury creates difficulty with travel, communication or participation in testing.

The examination report can affect access to treatment, financial support and the evidence in a lawsuit. Understanding the request before attending is far better than trying to address a harmful report after it has already been written.

Speak With Foster Injury Law About an Independent Medical Examination

Foster Injury Law is an Ontario personal injury law firm which represents people across Ontario dealing with serious injuries, catastrophic impairment disputes, accident benefits denials and personal injury lawsuits.

If an insurer has required you to attend an examination, or if a defence medical examination has been requested in your lawsuit, you should understand what is being assessed and how the report could affect your claim

Contact Foster Injury Law for a free consultation about an independent medical examination or serious injury claim in Ontario.

By Lane Foster, Personal Injury Lawyer