IMEs in PIP Claims: Your Rights, Responsibilities, and Recourse

After a car accident, insurance companies sometimes ask claimants to see a doctor of their choice. They call this an Independent Medical Exam, or IME, and it plays a key role in Personal Injury Protection (PIP) claims. The insurer selects a physician — typically a specialist in the relevant field — to evaluate the claimant’s injuries, treatment, and ongoing need for benefits.

Understanding how IMEs work in the NY no-fault system is essential for adjusters, claimants, and carriers alike.

Why IMEs Are Used in NY PIP Claims

New York’s no-fault system is designed to pay benefits quickly, without requiring proof of fault. But this efficiency creates an exposure: benefits are paid to anyone who files a valid claim, regardless of whether ongoing treatment is medically necessary.

IMEs serve several critical functions:

Verify injury: Confirm that the claimant’s reported injuries are consistent with the mechanism of accident
Assess necessity: Evaluate whether ongoing treatment is medically necessary and appropriate
Establish maximum medical improvement (MMI): Identify when the claimant has recovered as much as can be expected
Support denial: When an IME physician finds no support for continued treatment, the insurer can deny further benefits with a legal basis

Without IMEs, NY’s no-fault system would be even more vulnerable to treatment mills billing indefinitely for minimally injured claimants.

The Legal Framework

New York Insurance Law and the No-Fault Regulations (11 NYCRR Part 65) govern IME use:

The insurer’s right: Carriers are entitled to require claimants to submit to IMEs as a condition of no-fault coverage. This right is essentially unlimited — there’s no cap on how many IMEs can be requested, though they must be used in good faith.

The claimant’s obligation: Failing to appear for a properly noticed IME is a basis for denying all no-fault benefits — including medical and lost wages. This is a powerful consequence, and courts have upheld it.

Notice requirements: IME notices must be sent to the claimant at their last known address, with reasonable advance notice. The regulations specify requirements for what the notice must contain.

The 30-day rule interaction: An IME request tolls the insurer’s 30-day obligation to pay or deny bills. The clock stops running while a timely-requested IME is pending.

Selecting the Right IME Physician

The quality of an IME depends entirely on the quality of the examining physician. Selection criteria:

Specialty alignment: The examining physician should be in the same specialty as the treating providers (an orthopedist for orthopedic treatment, a neurologist for TBI claims)
NY no-fault experience: Physicians unfamiliar with the no-fault framework produce reports that don’t address the right legal questions
Report quality: Consistently detailed, well-reasoned reports that will withstand arbitration scrutiny
Availability and speed: Especially important given the 30-day timing pressures

Claimant Rights in the IME Process

While insurers have broad IME rights, claimants have protections too:

Right to representation: Claimants may have an attorney present at an IME, though the attorney may not interfere with the examination.

Right to a copy of the report: Claimants are entitled to receive a copy of the IME report.

Right to challenge: If a claimant disputes the IME findings, they can submit their treating physician’s records and opinions in arbitration — the IME report is not automatically dispositive.

Right to accommodation: If a claimant has a legitimate reason they cannot attend a scheduled IME (medical emergency, transportation issue), the insurer should reschedule in good faith before issuing a no-show denial.

IME No-Shows: The Consequences and the Process

When a claimant fails to appear for a properly noticed IME, the consequences are significant — but the process must be followed precisely.

Notice requirements for no-show denials: Courts have required that insurers provide the claimant with notice of the missed IME and an opportunity to reschedule before issuing a final denial based on non-compliance.

Documentation: Document every step of the IME scheduling and notice process. The denial will be challenged, and your records need to be airtight.

Arbitration: Most IME-based denials end up in arbitration. A well-documented file, with a quality IME report from an appropriate specialist, gives the carrier a strong position.

Best Practices for IME Programs

For TPAs managing high-volume PIP portfolios:

Establish vendor relationships with IME companies that have qualified physicians across relevant specialties
Automate scheduling triggers based on treatment patterns and billing thresholds
Track IME outcomes — report on denial rates, upheld denial rates in arbitration, and average benefit savings per IME
Train adjusters on proper notice procedures to avoid technical defeats in arbitration
Review IME reports before issuing denials — a poorly written report is worse than no report

The IME is one of the most powerful tools in the NY PIP adjuster’s toolkit. Used properly, it protects carriers from paying for unnecessary treatment. Used carelessly, it generates arbitration exposure and bad faith risk.

Aegis One manages end-to-end IME programs for our carrier clients, including vendor selection, scheduling, notice compliance, and denial support. Learn more about our capabilities →