Occupational medicine
CASE-25-D — Independent Medical Examination
Authored demonstration. Not a live employer result.
01 · Situation
The decision was made before the answer came back.
Illustrative IME ordered to resolve a disputed restriction; a benefit decision is issued before the IME report returns.
02 · Evidence
What the record holds.
- E1IME order
Verified · Day 0
- E2Scheduling confirmation
Verified · Day 2
- E3IME report
Not located · Due Day 21, per this demonstration’s illustrative case protocol
- E4Benefit decision issued without IME input
Verified · Day 22
03 · Obligations / Owners
The chain of responsibility.
- 01
Claims examiner (order the IME)
- 02
IME vendor (deliver report by Day 21, per the illustrative case protocol)
- 03
Decision-maker (incorporate findings before deciding)
04 · Accountability Break
Where the chain broke.
The decision deadline overrode the requirement the decision was supposed to depend on.
05 · Next Action
The corrective obligation.
Reopen the decision pending the IME report; add an escalation trigger five days before any decision deadline with an open IME.
06 · Economic Boundary
Where the evidence stops.
Not established.
07 · Engine Answer
What the Engine can and cannot establish.
The decision-maker was required by this demonstration’s illustrative case protocol to incorporate the IME report, due Day 21, before issuing a benefit decision. The record shows the IME was ordered and scheduled, but no report is evidenced, and the decision was issued on Day 22 anyway. The Engine can demonstrate that a decision was made without an input the process itself required. It cannot establish why the report was late or whether the decision would have differed.
A decision was made about a question that hadn’t been answered yet.