Examinations, Lawsuits, and Beneficiaries

Physical Examination and Autopsy Provision

The physical examination and autopsy provision is a mandatory uniform individual health policy provision under NAIC model law. This provision grants the insurer the right to examine the insured person as often as reasonably necessary while a claim is pending. For example, insurers may request independent medical examinations to verify the ongoing validity of disability income claims. If the insured refuses a reasonable, insurer-paid physical examination during claim review, benefits may be delayed or denied, subject to the policy and applicable law.

Company-requested physical examinations during claim review must be conducted at the insurer's expense. The insured is not required to pay any part of the cost for an independent medical examination requested by the insurer. Whether the insurer requires one examination or several reasonable follow-up evaluations to substantiate a continuing disability, the financial responsibility rests entirely on the insurance company.

The insurer also has the right to conduct an autopsy in the event of death where it is not prohibited by law. An autopsy requested by the insurer must be performed at the insurer's expense. However, this right is not absolute. The insurer cannot perform an autopsy if state law expressly forbids it, nor can it conduct one if the deceased person's religion or family objections are protected under applicable law.

Autopsy rights are particularly relevant in accidental death and dismemberment policies to confirm the cause of death. The insurer uses an autopsy to determine whether an insured's death was caused by an accident or by sickness. In addition, if an accidental death claim involves suspected suicide, the insurer may request an autopsy if permitted by law to evaluate whether benefits are payable.