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What is a qualified medical evaluator for workers' compensation?

Being injured on the job is no small thing. An individual may experience significant pain, incur a massive amount of medical debt and face the challenges imposed upon them by lost wages. Fortunately, workers' compensation benefits are available to most of these Californians who have been hurt in a workplace accident. There are some people, though, whose claims are denied for a variety of reasons. There may be disagreement about whether the accident occurred while the worker was performing his job duties, or about whether the claim was filed in a timely fashion. Yet, one of the most common reasons workers' compensation claims are denied is because the injury is not serious enough to keep the individual out of work. This can affect not only an initial claim, but also the amount of benefits received.

This issue often arises when an injured worker's medical professional has a different view on the injuries than the administrator handling the workers' compensation claim. When this happens and a question is raised as to whether the injury qualifies for workers' compensation, a qualified medical evaluator may be appointed to the case. The QME then analyzes the case and makes a final determination.

So who are these QMEs? They are doctors who have additional qualifications, such as additional education and licenses. Additionally, these individuals are tested by the state to ensure they meet medical knowledge requirements. They are also educated about the workers' compensation process and how claims are assessed and adjudicated. In some instances, though, an injured worker and the claims adjudicator may be able to agree on a medical professional to assess the case. Regardless, whoever is chosen to analyze the worker's medical condition will then issue an opinion about whether the injuries are work-related.

This issue highlights just one of the many that can arise when trying to seek out workers' compensation benefits. It's a challenging process that has many pitfalls leading to benefit denial. With that in mind, injured workers may want to discuss their situation with a legal professional before moving forward with a workers' compensation claim.

Source: State of California Department of Industrial Relations, "If my claim was denied," accessed on Apr. 17, 2017

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