What happens when your doctor and the insurance company don’t agree about your injury

If you’ve been hurt on the job in California and your treating doctor and the insurance company’s doctor don’t see eye-to-eye, your case may go to a QME — a Qualified Medical Evaluator. This is one of the most important steps in a workers’ comp case, and a lot of injured workers have never heard of it until they’re already in the middle of it.

 

What Is a QME?

 

A QME is a physician certified by the State of California’s Division of Workers’ Compensation to give an independent medical opinion when there’s a dispute in your case — usually about whether your injury is work-related, how much permanent disability you have, or what treatment you need. The QME is not your doctor and is not the insurance company’s doctor. They’re supposed to be neutral.

 

When Does a QME Get Involved?

 

• The insurance company disputes that your injury happened at work, or disputes part of it
• There’s a disagreement about whether you’ve reached maximum medical improvement
• There’s a dispute about your permanent disability rating
• You don’t have a lawyer and disagree with a decision your treating doctor or the insurance company made

 

How the Panel Process Works

 

If you’re represented by an attorney, either side can request a QME panel. The Division of Workers’ Compensation Medical Unit issues a panel of three doctors in the appropriate specialty. Each side then has the right to strike one name from that list of three within a set number of days — the doctor left standing becomes your QME.

If you don’t have an attorney, the process is different: you’re generally assigned a random three-doctor panel and you pick which of the three you want to see, without either side striking names first.

 

Why this matters: The doctor who ends up seeing you can have a major effect on your case — on how much permanent disability you’re rated at, and how much money you ultimately recover. Missing a deadline to strike a name, or not understanding the process, can mean you end up seeing a doctor who isn’t a good fit for your case.

 

What Happens at the Exam

 

The QME will review your medical records, take a history, examine you, and write a formal report. That report becomes evidence in your case — both sides can question it, and if there are follow-up questions, written questions can be sent to the QME under strict rules about who can contact them and how.

Bottom Line

The QME process has strict deadlines and strict rules, and it’s easy for an unrepresented worker to lose ground simply by not knowing the process. If your case is heading toward a QME, that’s exactly the moment to have an experienced workers’ comp attorney in your corner.