You may already have a treating doctor, a diagnosis, and an accepted workers’ compensation claim when another medical evaluation becomes part of the case. That can feel unnecessary, especially when your own physician has followed your recovery for months. In California, however, disputes over medical issues in a workers’ compensation claim may require an evaluation by a qualified medical evaluator, or QME.
For police officers, firefighters, and other first responders, a QME can become an important part of the claim because the evaluator may reach a very different conclusion from your treating physician. In today’s post, our experienced work comp attorney in San Diego explains why a QME may be requested and how the doctor’s findings could affect your benefits.
Why might a first responder need a QME in California?
California uses QMEs to help resolve medical disputes that have not been settled through the treating physician’s report. A QME is a physician certified by the Division of Workers’ Compensation to perform medical-legal evaluations.
A QME may be needed when there is a dispute about issues such as:
- Whether your injury or condition is work-related
- Whether you still need work restrictions
- Whether you can return to your regular duties
- Whether you have permanent disability
- Whether you will need future medical care
- Whether you remain temporarily disabled
A QME can address whether you may need future medical care, but it does not decide disputes over a specific treatment request denied through utilization review. Those disputes generally go through California’s independent medical review process.
What happens during a work comp QME in San Diego?
A QME generally reviews your medical history, asks about the work injury and current symptoms, and performs an examination related to the issues in dispute. The evaluator may also review imaging studies, treatment records, prior medical history, and information about your work duties.
You should answer questions accurately and avoid guessing when you do not know something. Be clear about what you can and cannot do, but do not exaggerate your limitations.
First-responder duties can also make context particularly important. Saying that you can walk, drive, or lift something does not necessarily explain whether you can safely wear equipment through a full shift, restrain someone, climb with gear, or respond to an emergency. Make sure the description of your abilities reflects what your actual job requires.
What happens if you miss a QME deadline?
Ignoring the QME process can affect how much control you have over the evaluation. For an unrepresented injured worker, California generally gives you the first opportunity to request the QME panel after the claims administrator sends the necessary paperwork. If you do not submit the request within 10 days, the claims administrator may request the panel and choose the medical specialty.
Once the Division of Workers’ Compensation issues a panel of three QMEs, an unrepresented worker generally has 10 days from the date the list is printed and mailed to choose a doctor, schedule the examination, and notify the claims administrator. If you miss that deadline, the claims administrator may choose the QME and arrange the appointment.
That does not mean every medical-exam issue should go unquestioned. California has detailed rules governing the QME process, including how doctors are selected, what records can be sent, and when a replacement panel may be available. If you receive QME paperwork or have concerns about an upcoming examination, review the request before letting an important deadline pass.
How can I contact a driven work comp attorney in San Diego who can help with a QME dispute?
Don’t make the mistake of treating a QME lightly. The evaluator’s opinion can affect disputes involving your work restrictions, temporary disability, permanent disability evaluations after reaching MMI, ability to return to duty, and other parts of the claim.
Whether you’re located close to Balboa Park or anywhere else in SD, Golden State Workers Compensation can help you understand what the evaluation means and what options remain when a QME opinion conflicts with the treating physician’s findings.
If you have received QME paperwork, have an examination coming up, or need to understand what happens when work comp refuses to authorize treatment, contact us for a free consultation. We’ll use all legal means to protect your best interests and help you determine what steps to take next. Call us today!
