Workers’ compensation is a vital system in California that helps protect employees who have been injured or become ill due to their jobs. One of the most important parts of this system is the medical evaluation process. Without medical evaluations, workers might struggle to prove the extent of their injuries or illnesses, making it difficult to receive the benefits they deserve. These evaluations play a big role in determining what kind of care an injured worker needs and how much compensation they are entitled to receive.
Medical evaluations are not just a single doctor’s visit. They often involve multiple steps, doctors, and reports that can all impact the outcome of a workers’ compensation claim. Understanding how these evaluations work and what role they play in the larger workers’ compensation process is essential for anyone who has been hurt on the job or is dealing with a work-related illness. At,The Myers Law Group, APC , we are here to guide you through the legal process and help you navigate the complexities of your case.
David P. Myers
Managing Partner
Adam N. Stern
Attorney
Ann Hendrix
Attorney
Robert Kitson
Attorney
Justin Crane
Attorney
Doug Smith
Attorney
Jason Hatcher
Attorney
Morgan J. Good
Attorney
Alvin Ferrara
Attorney
What is a Medical Evaluation in a Workers’ Compensation Case?
When an employee in California is injured or becomes ill due to their work, the first step in filing a workers’ compensation claim is usually seeing a doctor. This first doctor’s visit is often referred to as a medical evaluation. The doctor will examine the injured worker, look at their medical history, and try to determine the cause of the injury or illness. After this visit, the doctor will create a medical report that outlines their findings.
This medical report will include details about the worker’s condition, such as the type and severity of the injury or illness. It will also outline the treatment the worker needs and whether the worker can return to their job. In some cases, a doctor might say that the worker can return to work with certain restrictions, such as not lifting heavy objects, or the doctor might say that the worker cannot return to work at all. These findings will be important for determining what type of workers’ compensation benefits the injured worker can receive.
In California, there are different types of doctors who can conduct medical evaluations for workers’ compensation cases. These include the worker’s primary treating physician, a Qualified Medical Evaluator (QME), or an Agreed Medical Evaluator (AME). These doctors are crucial in helping determine the level of injury and how much compensation the worker is entitled to.
The Role of Primary Treating Physicians in Workers’ Compensation
The primary treating physician plays a key role in the medical evaluation process. This is usually the first doctor an injured worker will see after getting hurt on the job. The primary treating physician is responsible for treating the worker’s injury or illness and overseeing their recovery. They will also provide regular updates to the workers’ compensation insurance company about the worker’s progress.
The primary treating physician’s reports are used to decide what benefits the worker is entitled to. For example, if the doctor determines that the worker cannot return to their job, they might be eligible for temporary or permanent disability benefits. If the worker is recovering and can return to work with restrictions, the doctor will recommend any accommodations that might be necessary to help the worker return to their job safely.
The opinion of the primary treating physician is important because they have the most direct contact with the injured worker and are responsible for their care. However, in some cases, the insurance company or the employer might not agree with the findings of the primary treating physician. When this happens, a Qualified Medical Evaluator or Agreed Medical Evaluator might be needed.
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What is a Qualified Medical Evaluator (QME)?
A Qualified Medical Evaluator, or QME, is a doctor who has been certified by the Division of Workers’ Compensation (DWC) to conduct independent medical evaluations for workers’ compensation cases. If there is a disagreement between the worker and the insurance company about the worker’s medical condition, a QME might be brought in to help resolve the issue.
The QME will conduct their own medical evaluation of the worker and provide an independent report. This report will be used by the workers’ compensation judge to decide what kind of benefits the worker should receive. The QME’s report can either support or contradict the findings of the primary treating physician.
In California, if a worker or the insurance company disagrees with the medical findings of the primary treating physician, they have the right to request a QME. The worker will be provided with a list of three QMEs, and they can choose one from the list. This process ensures that the medical evaluation is fair and unbiased.
What is an Agreed Medical Evaluator (AME)?
In some workers’ compensation cases, the worker and the insurance company might agree on which doctor should conduct the medical evaluation. This doctor is called an Agreed Medical Evaluator, or AME. The AME is usually used when both sides want to avoid the time and expense of having a QME perform the evaluation.
The AME’s role is similar to that of the QME. They will conduct an independent medical evaluation of the worker and provide a report. The difference is that the AME has been agreed upon by both the worker and the insurance company. This often makes the process smoother and faster, as both sides are more likely to accept the findings of the AME.
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How Medical Evaluations Impact Workers’ Compensation Benefits
The findings of a medical evaluation are critical in determining the benefits that an injured worker can receive. In California, workers’ compensation benefits can include medical care, temporary disability benefits, permanent disability benefits, and job retraining. The type and amount of benefits a worker is entitled to will depend largely on the findings of their medical evaluation.
For example, if the doctor determines that the worker’s injury or illness is temporary and that they will recover, the worker might receive temporary disability benefits while they are unable to work. If the injury is permanent and the worker is unable to return to their job, they might receive permanent disability benefits.
In addition to disability benefits, the medical evaluation will also determine what kind of medical treatment the worker needs. This can include things like surgery, physical therapy, or ongoing medical care. The workers’ compensation insurance company is required to pay for all medical treatment that is necessary to treat the worker’s injury or illness.
Medical evaluations also play a role in determining whether the worker can return to their job. If the doctor finds that the worker can return to their job with certain restrictions, the employer might be required to make accommodations. If the doctor finds that the worker cannot return to their job at all, they might be entitled to job retraining or permanent disability benefits.
The Importance of Accurate Medical Evaluations in Workers’ Compensation Cases
Because medical evaluations are so important in determining the benefits a worker will receive, it is essential that these evaluations are accurate and thorough. A mistake or oversight in the medical evaluation process can lead to a worker receiving less compensation than they are entitled to or having their claim denied altogether.
In California, workers have the right to dispute the findings of their medical evaluation if they believe it is incorrect. This can be done by requesting a QME or AME, as discussed earlier. Workers also have the right to seek a second opinion if they are unhappy with the care they are receiving from their primary treating physician.
It is also important for workers to be honest and thorough when providing information to their doctors. The doctor’s findings will be based on the information provided by the worker, so it is important to be as accurate as possible. Workers should make sure to tell their doctor about all of their symptoms and any changes in their condition.
Medical evaluations play a crucial role in California workers’ compensation cases. They determine what benefits an injured worker can receive, what kind of medical treatment is necessary, and whether the worker can return to their job. Because these evaluations are so important, it is essential to have legal help when navigating the workers’ compensation process.
The Myers Law Group, APC is here to help you understand your rights and guide you through the complexities of a workers’ compensation claim. Our experienced attorneys will work with you to make sure you receive the benefits you deserve. If you have been injured on the job and are dealing with the workers’ compensation process, contact The Myers Law Group, APC today for a consultation. Let us help you get the compensation and care you need to recover from your injury and move forward with your life.