It’s a critical question for insurance adjusters and employers alike, especially when a claim involves chronic pain, degenerative conditions, or delayed symptom onset.
In the world of workplace injury claims, few questions are as common - or as complicated - as this:
“Is the worker’s condition caused by their job, or is it the result of something else?”
It’s a critical question for insurance adjusters and employers alike, especially when a claim involves chronic pain, degenerative conditions, or delayed symptom onset. Sorting through medical history, timelines, and symptom progression isn’t always straightforward - and that’s exactly where Independent Medical Examinations (IMEs) come in.
The Causation Puzzle
When a worker reports pain or impairment, it’s not always immediately clear if the issue is:
- Directly caused by a workplace incident
- An aggravation of a pre-existing condition
- Entirely unrelated to the job
The legal and financial implications of this determination are significant. But without objective medical insight, decisions are left open to interpretation - or worse, assumption.
The Role of the IME: Objective, Expert, and Independent
An IME provides an impartial, third-party medical opinion on the nature and cause of an injury or illness. Conducted by a qualified specialist with no treating relationship to the patient, the IME offers clarity where standard documentation may fall short.
At SOMA, our panel of assessors includes orthopaedic surgeons, physiatrists, neurologists, psychologists, psychiatrists and occupational medicine specialists - professionals who are trained to:
- Conduct comprehensive clinical evaluations
- Review detailed medical histories and diagnostic imaging
- Apply evidence-based frameworks for causation analysis
- Provide clear, defensible reports that stand up to scrutiny
What IMEs Look For When Determining Causation
When assessing whether an injury is work-related or pre-existing, IME assessors focus on several key factors:
1. Mechanism of Injury
Does the reported incident align with the diagnosed condition? Is the timeline of symptom development consistent with what is medically expected?
2. Pre-Existing Conditions
Are there signs of prior injury, degeneration, or chronic disease (e.g., arthritis, disc pathology) that would explain the current symptoms?
3. Functional Baseline
Was the employee functioning normally before the reported injury? Have they had limitations in this area before?
4. Medical Evidence
What do imaging studies, past medical records, and treatment notes show? Is there documentation of prior complaints or related conditions?
5. Aggravation vs. Exacerbation
Was the pre-existing condition permanently worsened (aggravation) or temporarily flared up (exacerbation)? This distinction often impacts claim validity and entitlements.
Real-World Examples
- A warehouse worker reports low back pain after lifting a box. Imaging shows disc degeneration that predates employment. An IME may determine that the work activity temporarily exacerbated a chronic condition, rather than causing it outright.
- An office worker with no history of shoulder issues develops rotator cuff symptoms after a fall at work. Clinical findings and the timeline support a direct workplace injury, despite age-related degeneration seen on imaging.
IMEs are not about denying claims - they’re about understanding them.
Why Employers and Insurers Rely on IMEs
When a claim is unclear or contested, an IME can:
- Reduce delays by offering timely, evidence-based clarity
- Support fair outcomes for both worker and employer
- Help guide modified duties or return-to-work planning
- Ensure decisions are legally defensible and medically sound
At SOMA, our medical team understands both the clinical and administrative needs behind every referral. We work with case managers, insurance carriers, and employers to deliver reports that are thorough, objective, and easy to interpret.
Closing Thoughts: When in Doubt, Refer It Out
In complex or borderline cases, don’t rely on guesswork. An IME is one of the most effective tools available to clarify causation, ensure fair decisions, and maintain the integrity of the claims process.
If you're reviewing a case and wondering “Is this really a workplace injury?” - it may be time to book an IME.
Contact SOMA Medical to speak with our team or make a referral today.
