Worker, Employer, Attorney, Insurer.
After an injury or illness on the job, several people will work with you to decide when you are ready to return to work and the compensation you may be entitled to. These people include:
- Your primary treating doctor
- Your employer (supervisors or other in management)
- The claims administrator
- Your attorney, if you have one
You should actively communicate with your treating doctor, your employer and the claims administrator about the following issues:
- The work you did before you were injured
- Your medical condition and the kinds of work you can do now
- The kinds of work your employer could make available to you or whether your job duties can be changed during your recovery.
At some point during your claim, you or the claims administrator might disagree with what your treating physician reports about your injury or treatment. When there is a disagreement, your option is to be evaluated by a Qualified Medical Evaluator (QME). The QME, a physician who must meet additional educational and licensing requirements, must also pass a test and participate in ongoing education on the workers’ compensation evaluation process. If you have an attorney, your attorney and your claims administrator might agree on a doctor to resolve medical disputes. In that case, this doctor is called an Agreed Medical Evaluator (AME).
If you act quickly, you may select the QME and take the QME exam, or you, your attorney or the claims administrator can request a QME exam if:
- Your claim is delayed or denied and you need a medical exam to find out if the claim is payable
- You need to find out if you are permanently disabled in some way or if you’ll need future medical treatment
- You disagree with what your doctor says about your medical condition
- You disagree with the finding of utilization review (to deny, delay or modify treatment)
You will also receive a letter that explains how to set up the QME appointment and how to provide the QME with important information. Within 10 days of the date on the list, you must pick a QME, make an appointment and tell the claims administrator. If this is not done, the claims administrator may select the doctor and make the appointment for you.
DISCLAIMER: The above is a general outline on how the QME process works. Obviously each case is unique. Unrepresented workers should consult the Information and Assistance Officer at the WCAB. Represented workers should consult their attorney.