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DEPARTMENT OF ENERGY, LABOR, AND ECONOMIC GROWTH OFFICE OF FINANCIAL AND INSURANCE REGULATION INSURANCE POLICY FORMS –
INDEPENDENT MEDICAL EXAMINATION STANDARDS
Filed with the Secretary of State on These rules take effect May 1, 2010
(By authority conferred on the commissioner of the Office of Financial and Insurance Regulation by sections 210, 2236, and 3151 of 1956 PA 218, 1969 PA 306, E.R.O. 2008-1, MCL 500.210, MCL
500.2236, MCL 500.3151 and MCL 24.231 to MCL 24.233, MCL 445.2005)
Draft 11/12/09
R 500.2251, R 500.2252, R 500.2253, and R 500.2254 are added to the Michigan Administrative Code as follows:
R 500.2251 Definitions.
Rule 1. As used in these rules:
(a) “Independent medical examination” means a physical or mental examination performed by a qualified physician or health professional at the insurer’s request for the purpose of determining a person’s health or condition as it relates to his or her claim for insurance benefits.
(b) Terms defined in the insurance code of 1956, 1956 PA 218, have the same meanings when used in these rules.
R 500.2252 Physician and health professional requirements.
Rule 2. To be reasonable under sections 2236 and 3151 of 1956 PA 218, MCL 500.2236 and MCL 500.3151, any clause or provision in an insurance policy form that authorizes or requires an independent medical examination or a physical or mental examination of a person shall not provide for a physician or health professional to perform the examination who fails to meet, at a minimum, the following standards:
(a) Holds a license as a physician or health professional in this state or another state of the United States.
(b) Has no history of disciplinary actions or sanctions, including loss of staff privileges or participation restrictions, that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body that raise a substantial question as to his or her physical, mental, or professional competence or moral character.
(c) Has the same or a higher level of education, certification, and if applicable, board certification, as the physician or health professional treating the subject of the independent medical examination.
(d) Has devoted a majority of his or her professional time, during the year immediately preceding the date of the examination, to active clinical practice, and/or instruction of students in an accredited health professional school or accredited residency or clinical research program, within the medical specialty most relevant to the subject of the independent medical examination.
Rule 500.2253 Costs and expenses.
Rule 3. To be reasonable under sections 2236 and 3151 of 1956 PA 218, MCL 500.2236 and MCL 500.3151, any clause or provision in an insurance policy form that authorizes or requires an independent medical examination or a physical or mental examination of a person shall not assess to the person to be examined any costs, including but not limited to the cost of the examination, the production of medical records, or travel expenses.
Rule 500.2254 Unreasonable independent medical examination clauses prohibited.
Rule 4. (1) A clause authorizing or requiring an independent medical examination in an insurance policy form subject to sections 2236 or 3151 of 1956 PA 218, MCL 500.2236 or MCL 500.3151, unreasonably reduces the risk purported to be assumed in the general coverage of the policy unless the physician or health professional meets the minimum standards specified in R 500.2252 and unless the person to be examined is not assessed costs and expenses as provided in R 500.2253.
(2) On and after the first day of the second month following the effective date of these rules, an insurer shall not issue, advertise, or deliver to any person in this state a policy, contract, rider, endorsement, certificate, or similar contract document that contains a clause authorizing or requiring an independent medical examination unless such clause conforms to the standards specified in R 500.2252 and R 500.2253. This rule does not apply to a contract document in use before that date but does apply to any contract document revised in any respect on or after that date.
(3) Nothing in these rules limits the commissioner’s authority under MCL 500.2236 to disapprove or withdraw approval of any form that contains an unreasonable independent medical examination clause.
