A qualified medical exam (QME) is performed by qualified physicians who are certified by the Division of Workers’ Compensation – Medical Unit to examine injured workers and note their disability in a medical-legal report. These reports are used to determine injured workers’ eligibility for workers’ compensation benefits.
Once a report is completed, your QME examiner has 30 calendar days to issue the results to you, the claims adjuster, and all attorneys involved in your claim.
Reasons a QME Can Be Delayed
There are three reasons why your examiner may request an extension on delivering your results. They include:
- The physician requested medical tests and is awaiting results
- The physician requested consultation and is awaiting a report
- The physician has a medical emergency and must delay the final report
It is important to note that a physician may not request an extension if the insurance claims adjuster fails to provide them with your medical records or past treatments. If the report is going to be delayed, the physician must file a time frame request with the DWC Medical Unit, as well as send a copy of the extension request to you. This must be filed five days before the report is due, according to Title 8, California Code of Regulations, section 38.
What Happens Once You Get Your QME Results?
If you do not have an attorney and your dispute does not involve a permanent disability, the QME will send a copy of the report to you, the insurance claims adjuster, and the Disability Evaluation Unit (DEU). The DEU will issue a rating within 20 days. Once a rating is given, you may begin discussing a settlement for your case with the claims adjuster. If you have a Workers’ Compensation Attorney, the QME will send them a copy as well and your attorney will advise you about all the next steps based on the evaluation you were given.
What Can Overturn a QME Rating?
If you received an unsatisfactory QME rating, there are certain scenarios where the rating can be overturned. The following are reasons why a QME determination can be reconsidered:
- New evidence emerges, altering the case’s medical findings
- Procedural irregularities occurred during the QME evaluation:
- QME has a pattern of giving inaccurate ratings
- A conflict of interest between the QME and those involved in the case
- Failing to consider a person’s physical requirements during the evaluation
- The final report contained factual errors and inconsistencies
- The QME failed to conduct an adequate medical examination
Is a QME Result Final?
While a QME’s rating carries a lot of weight in your claim, the final result is not set in stone. If you’re given a disability rating after a QME, your attorney, your employer, the insurance company, or the defense attorney can all formally dispute a QME’s finding through the Workers’ Compensation Appeals Board.
The Board will examine all medical evidence and testimony given on the matter to determine if the QME’s opinion warrants being overturned. Having your disability rating overturned is possible if you believe it is inaccurate. An experienced Workers’ Compensation Attorney can help you with the appeals process, as well as negotiate a fair settlement on your behalf.
Contact a Workers’ Compensation Lawyer in California
If you or a loved one has suffered a work-related injury and you are concerned about the QME process or have felt your workers’ compensation benefits have been inadequate, then the Attorneys at Maison Law can help. Our firm has helped numerous clients get the treatment they need and maximized their workers’ compensation benefits. Contact Maison Law today for a free consultation and case evaluation. No upfront money is required for our services and we don’t get paid unless we win your case.
