The insurance company has control of your medical treatment for the first 30 days following an industrial injury. This means that you are required to go to the doctor they select. However, after the 30 days has expired you can designate one primary treating physician of your own choosing to continue your medical care. This primary treating physician may refer you to other specialists for treatment, but all work status, etc. will be controlled by the primary doctor. This means that you cannot go to other doctors for treatment without specific referral from your primary doctor.
Generally, on an accepted claim the insurance has 7 days from the date of a request for authorization of treatment to either authorize the treatment or deny it. This deadline is not set in stone and can be extended for various reasons. Treatment can be denied due to several factors, the most common is that the insurance carrier’s medical review does not find that the treatment recommended is reasonable and necessary. As such a term is subjective in nature, the carrier is given wide latitude to make these determinations.
If a specific treatment is denied, there are a few options. First, you can proceed with the treatment through your private health insurance policy if one is available and then your insurance carrier will likely file a lien against your claim for payment when your case resolves. Another option is to proceed with the treatment on a lien basis directly with the medical provider. In such cases, the medical provider agrees to wait for payment until the end of your claim.
The final option is to request a hearing before the Workers’ Compensation Appeals Board. However, as the courts are extremely understaffed and overworked at this time, it is best to limit filing such a hearing request to only the most urgent of situations.
Either you or the insurance carrier can dispute the opinions of the treating physician, including the opinions on permanent disability, temporary disability, medical treatment, etc. If this occurs, either party can request a Medical/Legal evaluation by a Qualified Medical Examiner. A QME is a physician who has completed state requirements to obtain such a license. If you are not represented by an attorney, this QME is identified as a “Panel QME.” If you do not disagree with your doctor’s opinions, you should not select a Panel QME. However, the insurance carrier may still request that you go to a doctor they select for this evaluation that you must attend. The opinions of this doctor may or may not be considered for settlement of your case.
If you also disagree with your treating physician’s opinions, we suggest that you not select a “Panel QME” and immediately contact an attorney for possible representation. The reason for this is that once you have selected a “Panel QME” that doctor’s opinions then become binding on you for the remainder of the case even after you have retained an attorney. And many attorneys have a list of their own Medical/Legal evaluators they prefer to use.
Often times, your primary treating physician is excellent at providing treatment but because of the significant details required in writing final reports that are acceptable under Workers’ Compensation Guidelines. Other times, one or both parties may just disagree with the findings of your primary treating physician. In such cases, you will be required to attend a Medical/Legal evaluation. This evaluation can be determined two ways:
Agreed Medical Examination. This is where both your attorney and the defendants make an agreement on one doctor whose opinions would be binding on both parties. The benefit in using this evaluator is that it simplifies the examination and reporting process and usually allows for quicker settlement of your case. Your attorney will only use doctors that are regarded as being fair and impartial.
Qualified Medical Examination. One or both sides can proceed with an individual examination by their own expert doctor. This doctor’s opinions will then take the place of the opinions of your treating physician for whichever party requests the examination.
As both parties have the right to such examinations, you are required to attend any examination set up by your attorney and the defendants and you may be required to attend more than one examination with the QME selected.
Since 1987, Mehlhop & Vogt has been devoted to ensuring injured workers get the best medical attention and the workers’ compensation they deserve. Getting injured while on the job can affect your life in many different ways and due to the complexities in the legal process, having a workers comp attorney in Sacramento by your side is the best thing you can do for your future. Give us a call at (916) 930-9675 if you’ve been injured while on the job. Give us a call at (916) 930-9675 to speak to a work comp lawyer in Sacramento now.
There was excellent communication. If I didn’t understand something, Adam explained it. I was informed of what to be expected as the case was moving along. Very satisfied with the service.
I am very pleased with the services provided by Mehlhop & Vogt. The firm knows what they are doing and gets stuff done! I always felt respected and cared for. Adam always answered my questions right away and with great detail.
I liked the way Mr. Mehlhop handled my case, he was very professional at all times. I feel like he did the best he could considering my wages.