Let’s start with the basics.
A QME — short for qualified medical examiner — is a doctor who is licensed by the State of California. In workers compensation, a QME is an independent doctor who evaluates injured workers and write reports that address disability. A QME evaluation will only occur if there is a dispute over what benefits are due.
These disputes arise when an insurance companies denies your claim, or when either you or the insurance company disagrees with the opinion of a treating physician.
A QME is different than your treating physician because he or she is independent. If you are not represented by an lawyer, in most cases the insurance company will have chosen your primary treating physician for you.
I Got a Notice About a QME. What Does it Mean?
In most cases, one of two things has happened. The first possibility, is that the insurance company denied your claim and is informing you of your right to a QME. If this is the case, you should request the QME. Otherwise you’ll never receive any benefits.
The second possibility is that your treating physician has issued a final report. The insurance company will tell you whether they agree with this final report. You have the right to dispute the report and request a QME. In most cases, it makes sense for you to dispute the report and request a QME.
Think about what it means for the insurance company to agree with the report: It means they think it’s a good deal for them. Which means it’s probably a bad deal for you. In most cases it will be worth your time to be evaluated by the QME.
So request one.
How Does the QME Process Work?
When you request a QME, the workers compensation medical unit will issue a panel list with names of three QME doctors. This is frequently referred to as “the Panel”.
If you are not represented by a lawyer, then you will have 10 days to pick a doctor from the panel list of three names. If you fail to pick the doctor, then the insurance company will have the chance to do so.
Once the doctor is selected an evaluation will be set by the insurance company. Here are some answers to frequently asked questions about the evaluation setting process. These are provided by the State of California
After the evaluation, the doctor will issue a report. Hopefully this report will provide a higher level of disability for you. Most of the time it will. This is because the treating physician probably belongs to the insurance company’s medical provider network. That means there’s a contractual relationship between the treating physician and the insurance company. No surprise why the treating physician did not give you much disability.
After the report issues, the claim examiner will notify you what the results of the report are. This will most likely include the new settlement amount.
If you’re still not happy with the settlement figure, then it is probably best to get an attorney. Realistically, there’s not much left for you to do without being very familiar with workers compensation law.