By Donna Motley, Vice President of Claims 

The path an injured worker’s claim can take, can go in many directions.

The perfect claim would be: an employee sustains an injury in the course of employment; it is reported immediately to the employer (supervisor or Human Resources) per company protocol; the injured worker is immediately sent to the Occupational Clinic for an evaluation, diagnosis and treatment plan; the claim is filed with the MTMIC Claims Department within 24 hours of the injury; the injured worker may be off the “rest of shift” and return to work the next day, with or without restrictions; the injured worker returns to the clinic, the injury has resolved, a full release and discharge from care has been given; medical bills are forwarded to MTMIC for payment; and the claim closes in 90 days or shortly thereafter!

It may sound somewhat “drawn out” but, basically, this is an example of a “simple” claim.

Things happen, everyone is busy, obstacles occur. When things don’t go as planned, we have to adjust. One way we try to sometimes simplify matters, is the scheduling of an Independent Medical Evaluation (IME). We schedule the injured worker to see a doctor who specializes in the type of injury sustained or alleged by the employee. The doctor sees the injured worker one time, takes a thorough history, reviews all medical records (provided by MTMIC) and performs a medical examination. This doctor is not seeing the patient “to treat” – instead, they are to provide an evaluation as to diagnosis, causal relationship and proposed treatment plan (including whether or not the employee can return to work, with or without restrictions).

An IME may be scheduled when there are unusual or suspicious circumstances surrounding the alleged injury; for example, an injury is alleged to have occurred, but it was not reported for three months; or the alleged symptoms do not seem to coincide with the alleged mechanism of injury; or the alleged symptoms could be caused by the employee’s co-morbidities.

An IME may be scheduled if a claim was filed and the injured worker does not seem to be improving; we would request an evaluation to determine if the diagnosis we have is correct and utilize the evaluation like a “second opinion”. Maybe there is more than one proper diagnosis or the treating physician has missed something, or the injury is multifaceted and requires a complex treatment plan.

An IME may be scheduled if a claim has been filed and the current treating physician is not resolving the symptoms of the injured worker. It isn’t only about returning the injured employee to work, typically the injury is also keeping the employee from their normal daily activities and social life. The goal is to see progression of the healing process, an improvement in function at each scheduled doctor’s appointment. If progress is not seen, then something is wrong.

An IME may be scheduled if the treating physician feels the injured worker has reached “Maximum Medical Improvement”; we may want a second opinion.

Finally, yes, we may utilize an IME as a means to push the claim to an end, i.e. if we suspect a case of fraud. Typically, physicians working with Workers’ Compensation cases agree that the goal is to return the employee to pre-injury status and a successful return to all regular work duties. Some physicians may be more sympathetic than others and tend to coddle the injured worker. There is a difference between “sympathy” and “empathy”. Studies have clearly proven that the longer an injured worker is off work, the less likely they are to return to work. In that case, no one wins.

MTMIC has a very experienced staff of adjusters – we have all been handling claims in Michigan for many years. We know the best doctor’s with which to treat for a successful outcome – not just obtaining a “quick” return to work, but a successful resolution of the injury so the employee can return to their regular activities with no residual problems. In those cases – everyone wins!