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What Can an Injured Worker Do to Contest “Medical Determinations?”

Medical Determinations can be crucial in obtaining your rightful benefits for a workers’ compensation claim. But first, what exactly is a medical determination?

What is a Medical Determination?

In California workers’ compensation a ‘Medical Determination’ means that medical professionals specifically evaluate and diagnose work-related injuries or illnesses. When an injured employee files a workers’ compensation claim in California, their medical condition is assessed by qualified physicians or healthcare providers who specialize in occupational medicine.

Determining a medical condition involves comprehensive evaluation of the employee’s medical history, a physical examination, diagnostic tests, and any other relevant medical evidence for the claim. The healthcare provider examines the nature and extent of the injury or illness, its relationship to the employee’s work activities, and the impact it has on their ability to work.

The medical determination serves several purposes within the workers’ compensation system in California. It helps establish the connection between the employee’s condition and their job, determines the appropriate course of medical treatment, assesses the need for temporary or permanent disability benefits, and guides the overall management of the workers’ compensation claim.

In California, a medical determination plays a crucial role in determining the benefits an injured worker is entitled to receive. It influences the decisions made by the employer’s insurance company, the Workers’ Compensation Appeals Board (WCAB), and other parties involved in the claims process.

Can you contest a Medical Determination?

Contesting a medical determination in California workers’ compensation involves a formal process to challenge the findings or decisions made by the medical professionals involved in evaluating your work-related injury or illness.

What Can an Injured Worker Do to Contest “Medical Determinations”
What Can an Injured Worker Do to Contest “Medical Determinations”

Are you an injured worker in California who wishes to contest a medical evaluation done by a physician? For a smoother process, follow the steps below. Please note that the information provided is not legal advice. It’s important to note that an injured worker should consult with an attorney who specializes in workers’ compensation law to ensure that their rights are protected throughout the process.

1. Understand the Medical Determination

Familiarize yourself with the medical determination by reviewing the medical reports, evaluations, and any other relevant documentation. Understand the specific findings, diagnoses, treatment recommendations, and their implications for your workers’ compensation claim.

2. Request a Second Opinion

In California, you have the right to seek a second opinion from another qualified physician if you disagree with the initial medical determination. Your request for a second opinion can typically be made within the workers’ compensation system, following the appropriate procedures outlined by the Division of Workers’ Compensation (DWC).

3. Utilize Qualified Medical Evaluations (QMEs)

If the disagreement persists after the second opinion, you may request a Qualified Medical Evaluation (QME) from the DWC. A QME is an independent physician appointed by the DWC to evaluate your condition and provide an unbiased medical opinion. The QME process involves a selection of the QME from a panel or through a process called “Agreed Medical Evaluation” (AME).

4. Prepare for the QME Examination

When a QME is appointed, you’ll receive notification of the appointment along with the date, time, and location of the examination. It’s crucial to thoroughly prepare for the QME examination by compiling your medical records, documenting your symptoms, understanding your work-related activities, and being prepared to answer the QME’s questions.

5. Attend the QME Examination

Attend the scheduled QME examination and be prepared to provide an accurate and detailed account of your condition, symptoms, and limitations. Answer all questions honestly and provide any relevant documentation or medical records that may support your case.

6. Review the QME Report

Following the examination, the QME will prepare a report detailing their findings, opinions, and recommendations. Obtain a copy of the report and carefully review it to understand the QME’s assessment of your condition and how it may differ from the initial medical determination.

7. Addressing Disagreements

If you still disagree with the QME’s opinion, you can dispute their report by filing an objection with the DWC. This initiates a process called “Request for Reconsideration” or “Request for Qualified Medical Evaluator Reappointment,” depending on the circumstances. The objection should clearly state the reasons for the disagreement and provide supporting evidence, such as contrary medical opinions or additional medical records.

8. Utilize the Workers’ Compensation Appeals Board (WCAB)

If the dispute remains unresolved, you may file an appeal with the Workers’ Compensation Appeals Board (WCAB). The WCAB is an administrative court that handles workers’ compensation disputes in California. You will need to follow the specific procedures and deadlines set by the WCAB for filing an appeal.

9. Present Your Case

During the WCAB process, you’ll have the opportunity to present evidence; including medical records, expert testimony, and witness statements to support your position. It’s advisable to consult with an attorney experienced in workers’ compensation to guide you through the legal proceedings and help you build a strong case.

10. WCAB Decision

Following the presentation of your case, the WCAB will review the evidence and make a decision regarding the medical determination dispute. They may affirm the initial determination, accept the QME’s opinion, or provide an alternative resolution based on the merits of the case.

Consult with an Attorney

If you’re dissatisfied with the WCAB decision, you may have the option to further appeal to higher courts, such as the California Court of Appeal. This involves additional legal proceedings and should be discussed with your attorney.

Contesting a medical determination in California workers’ compensation can be a complex and lengthy process. It’s crucial to gather and present strong evidence, follow the established procedures, and seek legal advice to navigate the system effectively.

Remember, this information is a general overview, and consulting with an attorney who specializes in California workers’ compensation is recommended for personalized guidance tailored to your specific circumstances. Navarro Law Firm can help you determine your next steps. Contact us at 619-640-9200  for a free consultation or fill out a quick form.