If you are applying for California workers’ compensation benefits, you could face opposition from the claims administrator about the severity or cause of your workplace injury. They might even question whether the illness or injury was employment-related at all.
These, and more, questions could give rise to the need for a qualified medical evaluator (QME) on your case. Below is some important information to understand about the role of a QME in workers’ comp cases.
Are QMEs on your side?
At best, they will be neutral. These medical professionals, certified by the Division of Workers’ Compensation Medical Unit, perform legal and medical evaluations of claimants. They become involved when your doctor’s assessment of your condition gets called into question, and they may include:
- Osteopaths (D.O.)
- Medical doctors (M.D.)
All must be licensed by the state and are supposed to be neutral in their evaluations of claimants’ cases.
Does everyone get evaluated by a QME?
No. Clients with attorneys at least initially begin with examinations by agreed medical evaluators (AMEs) once questions arise over your doctor’s treatment and/or opinion of your diagnosis and prognosis. What that means is that both your attorney and the workers’ compensation attorney agree that this AME will review your claim and evaluate you legally and/or medically.
What happens when there is no agreement?
Enter the QME: This individual addresses matters like the following:
- Is your condition permanent or temporary?
- Is it stationary?
- Does your recovery require time off from work?
- Is your disability new?
- Did the accident/incident/illness worsen or exacerbate an existing disability?
- What is your permanent disability rating?
This is an incomplete list of issues QMEs determine. It is meant to give you an idea of questions they may seek to answer.
Reasons to ask for a QME
Since both your attorney and the opposing counsel can make a request, it can be at least marginally advantageous to request a QME first. Whoever asks the DWC Medical Unit for the QME gets to pick the specialty of the QME physician and choose one from a trio of randomly generated providers.
When your workers’ comp claim gets complicated, it may be time to see experienced guidance.