IME No-Shows

An IME is a medical examination by a physician selected by, or acceptable to, the insurer, which the mandatory endorsement requires you to attend "when, and as often as, the Company may reasonably require" (11 NYCRR 65-1.1). Insurers use it to verify the claim, including whether treatment remains necessary. An examination requested as verification must be scheduled within 30 calendar days from receipt of the verification forms, at a place and time reasonably convenient to you, in a properly equipped facility, with lost earnings and transportation reimbursed (11 NYCRR 65-3.5(d), (e)). If the report is the reason for a denial, you may demand a copy (11 NYCRR 65-3.8(b)(4)).

No. Attendance at the insurer's medical examinations, when and as often as reasonably required, is a term of the coverage, and full compliance is a condition precedent to suing the insurer (11 NYCRR 65-1.1). The Second Department holds that appearance at an IME at any time is a condition precedent to the insurer's liability, so a no-show can support denial back to the date of loss (Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 (2d Dept 2006)). What you can insist on is the regulation's terms: a reasonably convenient place and time, a properly equipped facility, and reimbursement of lost earnings and transportation (11 NYCRR 65-3.5(e)).

Bring photo identification, the scheduling letter and a list of your treating providers. Describe your symptoms, limits and treatment history accurately and completely; do not minimize and do not exaggerate. Expect a physical examination that may measure range of motion and strength. The examination must be held at a place and time reasonably convenient to you in a properly equipped facility, and the insurer must reimburse lost earnings and reasonable transportation expenses (11 NYCRR 65-3.5(e)). Afterward, request a copy of the report if it is used to deny benefits (11 NYCRR 65-3.8(b)(4)) and give it to your treating provider.

"Maximum medical improvement" is a medical opinion that your condition has plateaued and further treatment is unlikely to help. The term appears nowhere in Insurance Law Article 51 or 11 NYCRR Part 65. Its effect comes from two rules: first-party benefits cover only necessary expenses (Insurance Law § 5102(a)(1)), and an insurer may discontinue benefits when it has information which clearly demonstrates that the applicant is no longer disabled, by issuing the prescribed denial form (11 NYCRR 65-3.8(b)(2)). An MMI finding is not a finding that you recovered. Your treating provider can answer the report in writing, and the dispute goes to arbitration or court (Insurance Law § 5106(b)).

Yes. First demand the report: when a medical examination is the specific reason for a denial, the insurer must release a copy on written request (11 NYCRR 65-3.8(b)(4)). Your treating provider then answers it in writing, citing the findings, tests and measurements in the chart that the examiner ignored; that rebuttal may be an affirmation under penalty of perjury (CPLR 2106). The dispute is decided in arbitration or court at your option (Insurance Law § 5106(b)). Law changed January 1, 2024: CPLR 2106 lets any person affirm under penalty of perjury instead of swearing an affidavit; before then only New York attorneys and licensed health-care practitioners could.