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Workers’ comp: What happens if you disagree with a medical report?

Your employer’s workers’ compensation insurance triggers when you file a claim for a work-related injury. The insurance covers any initial medical costs you might incur. If your injuries result in a disability that prevents you from returning to work or limits your ability to work, workers’ compensation also pays you benefits.

But before an insurer can pay these benefits, a treating doctor must determine the type of work you can or can’t perform while recovering. The medical professional will also decide if your work schedule or assignments need changing due to your medical condition. These recommendations are listed in a medical report shared with your employer and the claims administrator.

You might find yourself in a situation where you disagree with the medical report. Perhaps the treating doctor underestimated the level of impairment you’re suffering and recommended that you quickly return to regular work despite the severity of your injuries. Or maybe the doctor unfairly determined that a non-work element caused a large portion of your disability.

What can you do if this happens to you?

Requesting a QME

Fortunately, California allows you to request an independent reevaluation. If an attorney represents you, they and your employer’s claims administrator can agree to pick a medical evaluator who can give a second opinion. If they can’t agree on an evaluator, they must request for a qualified medical evaluator (QME).

The list of QMEs you can pick from will come from California’s Division of Workers’ Compensation (DWC) Medical Unit. These state-certified QMEs are randomly selected and don’t represent your employer or their insurer.

The QME process

If your attorney and the claims administrator can’t agree on a medical provider, the latter will send you a panel request form for QMEs. You must fill out the form within 10 days of receipt, indicating the medical specialty of the QMEs that you need. If you fail to submit the form within the deadline, the claims administrator will pick the QMEs’ specialties.

Once you submit the request form, the DWC Medical Unit will send you a list of QMEs to choose from. You must pick one and undergo a medical evaluation. The QME has 30 days from the examination date to issue a new medical report.

Even if you get the second opinion of a QME, you might still disagree with the newer medical report. If this happens, consider consulting with your legal representative to understand your next options.