California workers who are injured on the job or suffer a related condition or illness that prevents them from working will understandably want to receive workers’ compensation benefits. Workers’ compensation is important as it not only allows a worker to receive partial payment of their wages, but it can help them with medical treatment. For those who are facing the uncertainty of a work-related injury, these issues will be worrisome. Not all cases go smoothly with the insurer and the worker agreeing on the extent of the injuries. In some cases, the claim can be denied.
If the denial or disagreement is based on a medical professional’s assessment, there are alternatives such as a qualified medical examiner (QME) or an agreed medical evaluator (AME). Understanding key factors about these evaluations is imperative. A QME is a physician with a license to practice in the state. They receive a certification by the Division of Workers’ Compensation Medical Unit and are legally allowed to evaluate a case based on medical or legal issues. AMEs are physicians who are picked by the worker’s legal representation and the defense. They also evaluate cases on a medical or legal basis when there is a workers’ compensation claim. An AME is only used when the worker is represented by a lawyer.
A QME or an AME is used when there is a disagreement between the injured worker or the workers’ compensation claims administrator and the treating physician. The following could be subject to disagreement: whether the worker suffered the injury or illness due to the work that he or she was doing; if there is treatment necessary for the injury; if the worker cannot work while recovering; if the condition is permanent and is not expected to change; if there are new disabilities; or the worker’s permanent disability rating is in question.
Since workers who are embroiled in a disagreement over their workers’ compensation claim may need legal advice, it is wise to have a lawyer. When there is a lawyer, the AME will be used since that physician is agreed upon by both sides of the dispute. When there is a disagreement over a workers’ compensation claim, it can cause a worker unnecessary anxiety and fear as he or she is already trying recover from the injury or condition. It is important to understand that a dispute does not mean that the claim will be denied and the worker will never get benefits. However, knowing how a medical examiner – QME or AME – is important to the case is critical. A law firm experienced in all areas of workers’ compensation can help.