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Insurance Company Rejection to QME ?
#1
This is in California.

I had a QME about 6 weeks ago, the QME report came and it stated I was not P&S and need to be back on light duty and the QME would issue a further report pending the MRI they sent me for, so back on light duty I went. I am in a holding pattern waiting for the QME report on the MRI and some direction after which I will be back to a insurance company dr for more treatment.

So today I get a letter stating the Insurance Company is objecting to everything the QME has said to date based on CA Labor Code 4060, 4061 and 4062 and they object on the fact the the QME can not act as the QME and the treating physician. However the QME only saw me once and has not treated me in any way. It further states they (Insurance company) are requesting a replacement QME panel.

I have a meeting later this week to obtain an attorney, which was actually set a couple weeks ago, so in the meanwhile I am not going to respond to this letter but I would sure like some insight from someone here who may have some knowledge on this.

Thanks in advance.
 
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#2
Once you are represented an Agreed Medical Examiner can be used and the QME issue can be moot.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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#3
further info:

it appears they are objecting because the QME report put me on light duty, however it was not specific as to what light duty entailed. SO my employer sent a form they use to the insurance company who in turn forwarded it to the dr so they (employer) could determine what light duty I could do. So it appears they are objecting to a form they got from my employer and sent to the QME doctor and got back at their request! Somehow they think that form is from the treating dr and that the treating dr is also the QME.....I think the insurance company is confused! (note, they did just give me a new case manager and I assume there was no communication between them, thus the confusion)


1171, thanks for the quick reply!

this QME is GREAT and I dont want to change, is it possible to keep the same QME once represented ?
 
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#4
I can see you don't understand the use of the word "agree".
What's the likelihood of the carrier agreeing to use the QME they objected to?
Read the fact sheet on use of AME
http://www.dir.ca.gov/dwc/iwguides.html

If they are confused then they will lose their objection.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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#5
(04-02-2013, 12:47 AM)1171 Wrote: I can see you don't understand the use of the word "agree".
What's the likelihood of the carrier agreeing to use the QME they objected to?
Read the fact sheet on use of AME
http://www.dir.ca.gov/dwc/iwguides.html

I have read it and understand the AME. However, even the attorney told me this QME is great when we spoke on the phone last week. I am sorry but I am confused and worried at this point that this great QME I have will be all for not....
 
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#6
to answer your question: The chances the carrier will agee to use the QME as an AME in my opinion are zero and you should hope the objection will be overruled.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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#7
will the attorney be able to submit info to state that the insurance company is confused?
 
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#8
maybe.
it's not a court and they don't have to review it.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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#9
in the meanwhile the QME assigned light duty, would that assignment stay? I assume it would until another medical professional ruled ?

Also, I am waiting on the QME's review and report on the MRI, any idea if that will still happen? Will the QME report/MRI results be accessible to the next dr to review?
 
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#10
i can provide information but not predictions; especially about others behavior when I'm not familiar with the case.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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