“Doctor shopping” is an activity both insurers and insureds can engage each having its own unique motivation. In a general sense, “doctor shopping” is defined as seeking multiple medical consultations, reports and/or opinions until the desired result is obtained.” “Doctor shopping” is considered to be a deceptive claims practice regardless of whether it is the insurance company doing it, or the insured.
Insureds engaging in “doctor shopping” continuously seek medical consultation from many physicians in an effort to obtain certification for disability. It is possible for insureds to become obsessed with obtaining medical certification when physicians disagree they are disabled and can return to work. All insureds are entitled to seek second and even third opinions involving medical specialists therefore a clear distinction must be made between those insureds legitimately seeking clarification of an illness, or specialty treatment, from those whose physicians are unwilling to support disability and the insured continues to search for a physician who will.
Insureds who engage in “doctor shopping” can become obsessed with medical support even to the point of preparing long diagnostic lists to present to new physicians. One insured had a prepared list of perhaps 20 diagnoses “she felt she had” and presented this list to some 30 physicians over a period of 6 months. Unfortunately, physicians catch on pretty quick and make notations in the patient file that “the patient thinks she has this” or, “the patient said he had a history of that.” Our recommendation to insureds who contact us is to always allow physicians to do their own tests and document their own diagnosis, treatment and certification for disability. Disability insurers are quick to recognize insureds who engage in “doctor shopping” in order to obtain certification for a disability that may or may not exist. Rarely does insured doctor shopping result in an approved disability claim. In extreme cases, insureds could be accused of insurance fraud by attempting to obtain benefits for secondary gain.
On the other hand, insurance companies are literally given permission via the policy contract to engage in “doctor shopping” by the state. Most policies contain a contract provision which basically says ” we may have you examined by a physician of our choice as frequent as is reasonable to do so.” This is one of the most egregious disability policy provisions that should be reconsidered by state authorities because it literally gives disability insurers contractual rights to engage in “doctor shopping” until the company is able to obtain an IME opinion favoring return to work and a claim denial.
Many insureds try to stalwart multiple requests for IMEs by claiming, for example, two IMEs in one year isn’t reasonable. In other words insureds often challenge the meaning of “reasonable” in order to stop new requests for multiple IMEs. Unfortunately, the “reasonable” challenge doesn’t work since it is the insurer who decides what’s reasonable and what isn’t. Insurers often take advantage of the policy wording allowing IMEs and can continue, contractually, to request IMEs over and over again until reports are finally obtained favoring claim denials. This type of “risk management” by disability insurers can be abused and harassing to insureds. In addition, the “reasonable” defense used by insurers also financially supports the thousands of insurance IME physicians who render opinions in favor of those who are signing the check. The more IMEs requested, the better.
Insurer requests for more than one IME are usually the result of a “trigger” such as a new surveillance. Typically, it’s difficult to deny claims based solely on surveillance, therefore insurers often request more than one IME when surveillance is seen inconsistently showing activities different from those reported by the insured and his/her physician. Medical patient notes documenting changes or improvement can also be used as “triggers” for new IME requests.
The bottom line is that companies such as The Hartford can legally request multiple IMEs until enough evidence is obtained in its favor to support claim denials. Recently, The Hartford is using an outsourced Physician IME Network to arrange IMEs at increasing numbers. In one claim situation The Hartford offered the client a lump sum buy-out and when he refused about a year ago requested he submit to one IME after another. One might view the frequent IME requests as punitive and the insured reported the requests to the insurance commissioner.
Although “doctor shopping” is an unfair claims practice and frequently used by disability insurers, contractual policy language literally allows insurers to continue “doctor shopping” for opinions it can use to deny claims.
