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When a worker suffers a job-related injury or illness, sometimes disagreements can arise over the specifics of the case. These disputes might include whether the injury was caused by work, the severity of the injury, disability benefits, the appropriate medical treatment, or the employee's ability to return to work. To settle these differences, a Qualified Medical Evaluation (QME) is used.
A QME is required to address all issues within the scope of their specialty. In the extent there are components of the case outside of their specialty, the injured worker may need to see a second QME.
Getting a second QME
To obtain a second QME, the injured worker needs either an agreement with the insurance company (spoiler alert, they rarely agree) or “good cause.” Essentially, “good cause” means an order from a Workers’ Compensation Judge. This process is different than obtaining a replacement QME.
To demonstrate “good cause” you need to show the following:
Disputed issues that would fall under Labor Code Sections 4060, 4061, or 4062
That another QME in a specialty different from the existing QME is necessary.
Here is an example of when you might need a second QME: An injured worker has a catastrophic back injury, and due to the injury, they have developed depression. The insurance company has admitted liability for the back, but not the depression component of the case.
If the initial QME is an orthopedic specialist, they would not be qualified to address the depression component of the case, so the injured worker would need to see a QME in psychiatry or psychology as well. Since it would be outside the scope of the initial QME and there is a dispute over liability, the injured worker should have good cause to get an order from a Judge for an additional QME Panel, assuming the insurance company does not agree in the first place.
Getting a replacement QME
Once a QME is selected it is difficult to replace them. If the injured worker is simply unhappy with the outcome of the evaluation, but the QME is qualified to address the type of injury the injured worker has and the QME followed the rules, it is unlikely they will be replaced unless there is a good reason.
Typical reasons why QMEs are replaced include, that they are no longer available for evaluations, reports, or depositions; bias; refusal to adhere to regulations governing their licensing; and failure to issue timely evaluation reports; the QME previously treated the injured worker; or the QME is not competent to address the claim.
Getting a QME replaced can sometimes be easy because both sides agree a replacement is needed. In which case, the parties complete a 8 CCR 31.5 Replacement Panel Request, then a new panel is issued. Other times, one side or another wants to keep the current QME, which means there is a disagreement. When this happens, this involves gathering evidence and taking the case to court for the Judge to decide whether there should be a replacement QME.
Conclusion
In conclusion, getting a second QME or replacing the current QME is a slow and complicated process. This is why it is incredibly important to choose the right QME and specialty in the first place. Otherwise, picking the wrong evaluator can have catastrophic consequences for an injured worker’s case that cannot be fixed.
Need help getting a replacement QME? Contact Pacific Workers’, The Lawyers for Injured Workers for a free, confidential case evaluation. Call us at 800-606-6999 or make an appointment here.
