Q. How do I file a workers' compensation claim?

A. You should first report the injury to your employer and obtain an Employee's claim form from the employer. Fill out the top half of the form, and the employer will fill out the bottom. You should receive a copy of the form and one will be sent to the employers workers' compensation carrier. Your employer can give you information on how to obtain care. Within 14 days of reporting the injury, you should hear from the carrier. The carrier will either accept, deny, or investigate the claim. Most claims are accepted, however the carrier has up to 90 days to investigate the claim without providing benefits. If you are unable to work and the injury is being investigated, you may check to see if you qualify for state disability payments. If you have private medical insurance, you may contact them to obtain treatment for the injury. If your employer does not provide you with an Employee's Claim Form, you may obtain one from any Division of Workers' Compensation information and assistance office.

Q. Who can give me information and help me understand the system?

A. Information and assistance officers work for the state of California and will assist you for free if you do not have an attorney. They will answer questions that you have regarding rights and benefits. They will also help resolve problems with the carrier, the employer, or in obtaining medical care. When you are ready to settle the claim, they will review the settlement. The majority of questions regarding a claim can be answered by the information and assistance officers. The Industrial Medical Council will assist you with questions about the qualified medical evaluator process.

Q. What is a QME?

A. A qualified medical evaluator (QME) is a physician who evaluates an injured worker when there are questions about what benefits the injured worker should receive. A QME has to meet certain requirements and pass a test before being appointed in this position.

A QME physician can do evaluations for injuries occurring on or after 1/1/91. A physician must meet educational and licensing requirements to qualify as a QME. They must also pass a test and participate in ongoing education pertinent to the workers' compensation evaluation process.

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QME evaluation process - Frequently
asked questions by injured workers

Q. What is first panel request?

A. A panel is a list of three QME physicians that is issued to an injured worker, who is not represented by an attorney, when there is a dispute that hasn't been answered by the treating physician's report (for injuries after 1/1/94). The injured worker chooses the specialty of the panel members.

Q. Who completes the panel request form?

A. Only the injured worker can complete the panel request form and choose the QME specialty. (IMC Reg. 30, 139.2(h), 4061(d), 4062(b))

Q. I have two different problems from the same injury (for instance a psychiatric and an orthopaedic claim). May I request two panels, one psychiatric and one orthopaedic?

A. For injuries prior to 1/1/94 - You may have two panels, one for the psychiatric claim and one for the orthopaedic claim.

For injuries on or after 1/1/94 - The carrier is only required to pay for one QME evaluation. You should contact the carrier to tell them about your request and to see if they will authorize payment for both evaluations. If the carrier says they will only pay for only one evaluation, you will have to choose one specialty. (Labor Code 4061 (d, g) and 4062 (b, c))

Q. Can I get a new panel because the physicians on the panel are too far away?

A. We cannot replace the physicians if they are less than 50 miles away from your address. We cannot simply choose the closest physicians as the process must be random. The carrier will pay for the transportation costs.

Q. The panel of QMEs you issued are close to my home. However, can you give me a panel closer to work?

The Labor Code requires us to issue panels close to the residence. The IMC can issue a panel of QMEs close to the workplace if the carrier agrees with the request. (Labor Code 139.2 (h), IMC Reg. §31.5 (b)(2))

Q. Can I get a second panel as two of the QMEs are unavailable for over 60 days?

A. We will send a panel with two new physicians to replace the ones that are unavailable within 60 days. Prior to sending the new panel, we will verify that a physician is unavailable within 60 days. (IMC Reg. §31.5 (a); 33 (c))

QME process | Records | Treating physician | Complaints | Insurance carrier problems

Injured worker - general questions on workers' compensation

Q. How do I file a workers' compensation claim?

A. You should first report the injury to your employer and obtain an Employee's claim form from the employer. Fill out the top half of the form, and the employer will fill out the bottom. You should receive a copy of the form and one will be sent to the employers workers' compensation carrier. Your employer can give you information on how to obtain care. Within 14 days of reporting the injury, you should hear from the carrier. The carrier will either accept, deny, or investigate the claim. Most claims are accepted, however the carrier has up to 90 days to investigate the claim without providing benefits. If you are unable to work and the injury is being investigated, you may check to see if you qualify for state disability payments. If you have private medical insurance, you may contact them to obtain treatment for the injury. If your employer does not provide you with an Employee's Claim Form, you may obtain one from any Division of Workers' Compensation information and assistance office.

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Q. Who can give me information and help me understand the system?

A. Information and assistance officers work for the state of California and will assist you for free if you do not have an attorney. They will answer questions that you have regarding rights and benefits. They will also help resolve problems with the carrier, the employer, or in obtaining medical care. When you are ready to settle the claim, they will review the settlement. The majority of questions regarding a claim can be answered by the information and assistance officers. The Industrial Medical Council will assist you with questions about the qualified medical evaluator process.

Q. The panel QME that I want to see is unavailable for three months. Can I wait for three months to see this QME?

A. Yes. You may wait to see this QME. (IMC Reg. §33)

Q. I showed the panel of QME's to my treating physician /friend/union representative and he/she does not feel any of the physicians listed will give a fair report. Will the IMC issue a new panel?

A. The panel of physicians is randomly selected by the computer. All the physicians on the panel have applied to the IMC to be a QME and have met all of the requirements to be a QME. Therefore, we are unable to issue a new panel. Only the WCAB has the ability to determine that a QME is biased or unfair. (139.2(h), 4068, IMC Reg. 50.3)

Q. I was issued a panel of orthopedists, at the carrier's request. However, will you issue a new panel as I want to see a chiropractor?

A. The injured worker chooses the specialty of the QME physician, so we will send you a new panel. (Labor Code 139.2h)

Q. Is it possible to replace the physician due to his nationality/accent/ too old /too young?

A. No, all of the physicians on your panel have met the IMC's requirements to be a QME and are licensed to practice in California. The QME physicians on the panel were randomly selected, and all QME's of the chosen specialty in the area must be included in the random selection. (Labor Code 139.2(1), 139.2(h))

Q. What happens when a physician on the QME panel is no longer a QME?

A. We will check our records to see if the physician is still an active QME. If he/she is not, we will replace the QME.

Q. Would the IMC issue a second panel because two of the QMEs listed are in the same office/ same medical group and I feel that this does not really give me a choice of three different QMEs?

A.Yes. We will issue a second panel replacing one of the physicians. (IMC Reg. 31.5 (a)(4))

Q. I have moved since the panel of QMEs was issued. Would the IMC issue new panel of QMEs closer to my new home?

A. Yes. We will issue a new panel closer to the new residence.(IMC Reg. 31.5 (4))

Q. Why do I have to go through the QME process when neither party (insurance carrier or me) is objecting to the treating physician's report?

A. For injuries prior to 1/1/94 - Per the labor code, the final evaluation to determine permanent disability and future medical care must be performed by a QME. (Labor Code § 4061(c))

For injuries on or after 1/1/94 - A QME evaluation is not required if both the carrier and you agree with the primary treating physician's final evaluation and it is a ratable report. (Labor Code §4061(d), §4061.5)

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Q. I moved out of California and would like to settle the case without going through the QME process. Is this possible?

A. Injuries from 1/1/91 - 12/31/93 - The carrier and you should contact the information and assistance office where the case is going to be settled to explore the options.

For injuries on or after 1/1/94 - If both parties agree with the treating physician's report, there is no need to attend a QME evaluation. If the carrier disagrees with the treating physician's report, and you refuse to attend a QME evaluation, the carrier may have to file a petition with the WCAB. They could ask that you be compelled to attend the evaluation.

Q. The QME evaluation was yesterday. How long does the QME have to issue the report?

A. This varies depending on the year of injury.

Injuries from 1/1/91 - 12/31/93 - The physician has 45 calendar days, from the date of the commencement of the exam, to issue the report.

For injuries on or after 1/1/94 - The physician has 30 calendar days, from the date of the commencement of the exam, to issue the report.

There are three reasons a physician may request an extension in issuing a report:

1. The physician requested you have medical tests and is awaiting results.

2. The physician requested a consult and is awaiting the consultant's report.

3. "Good cause" is a medical emergency of the evaluator or the evaluator's family, death in evaluator's family, natural disaster or other community catastrophes that interrupt the operation of the evaluator's office. The computer breaking down or a staff member quitting are not considered good cause. Extensions for good cause may not exceed 15 days from the date the report is required to be served.

The physician may not request an extension because the carrier failed to provide your medical records or past medical tests. If the report is going to be late, the physician must file a time frame extension request with the IMC and send a copy to the insurance carrier and to you. This must be filed five days before the report is due. (IMC Reg. §38)

Q. I just received the QME report. What happens next?

A. If you are unrepresented , the physician will send a copy of the report to the insurance carrier, to the Division of Workers' Compensation Disability Evaluation Unit (DEU) and to you. The DEU should issue a rating within 20 days. If a rating is not issued within 20 days, you may ask the carrier if they would rate the report rather than waiting for the DEU to issue a rating. If you have questions on the rating issued by the insurance carrier, you may discuss the rating with an information and assistance officer.

Once a rating is obtained, you may begin discussing settlement of the case with the insurance carrier. If you have questions on the settlement of your claim, call information and assistance. (Labor Code 4062 (c), 4061 (i))

Q. I need another evaluation. Should the original QME do another evaluation? What if that physician is no longer performing QME evaluations?

A. The second evaluation should be done by the same QME physician. Two exceptions to this rule are: 1) The physician is no longer a QME. 2) The physician became the treating physician after performing the QME evaluation. If either exception applies, the IMC will replace the QME who performed the evaluation. (Labor Code 4061 (g), 4062 (c))

Records - Frequently asked questions by injured workers

Q. What is the purpose of sending the medical and non-medical records to the QME?

A. These records give the QME a history of the injury. The physicians' records indicate the diagnosis and treatment received to date. Test results such as MRI's are forwarded so that the QME will not have to duplicate the tests. Medical records about treatment prior to the injury are often sent to help determine how much of the permanent disability is due to this injury and how much may be due to a prior injury or accident. Non-medical records, such as a letter from the carrier, are sent to provide information regarding the injury to the QME physician.

Q. What are the non-medical and medical records that are sent to the QME? Can I object to certain record being sent to the QME for review?

A. The carrier receives on an ongoing basis all the treating physician's reports, copies of x-ray results, and may obtain old medical records that relate to the current injury. All these are considered medical records. You do not have the right to object to any medical records being sent to the QME.

Non-medical records may include letters that the insurance carrier writes to the QME, personnel records, or, in some cases, films.

Once you make the QME appointment, the physician has five days to send the QME appointment notification form" to the carrier advising them of the appointment. The insurance carrier is required to send to you a copy of everything that they plan to send to the QME physician 20 days prior to sending the records to the QME. You are also required to send any information (letters from friends, personal records) that you are planning to send to the QME to the carrier 20 days before you send it to the QME. Either party has 10 days to object to any non-medical records being sent to the QME. There is no form; they simply write a letter to the other party. If either you or the insurer do not follow the 20 day rule, the wronged party has the right to cancel the evaluation. (Labor Code §4062.2 (e, f), IMC Reg. §35)

Q. The QME evaluation is next week , but I have not received the medical records and neither has the QME. What should be done?

A. There are two options: 1) You may cancel the appointment, call the carrier or treater to obtain the records, and then reschedule the appointment. 2) You may keep the appointment and have the carrier send the records to you and then to the QME after the evaluation. Some QMEs do not wish to perform an evaluation without the records, so check with the QMEs office to see if the appointment should be rescheduled.

Treating physician as a QME - Frequently asked questions by injured workers

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Q. What should I do as the carrier is objecting to one of the physicians on my panel (physician treated or evaluated me, physician is in the same office as the treating physician, physician is my primary treating physician)?

A. 1991-1993 injuries: The treating physician or any physician that has treated you may do the QME evaluation if his name appears on your panel. When compiling a list of QME's, the IMC includes all physicians of the appropriate specialty in the general geographic area of your residence and has no authority to exclude evaluators based on any other criteria. If the treating physician appears on the panel, you may select him to do the evaluation. You may choose any physician who appears on the panel. (Labor Code §139.2(h))

1994 - to present injuries: Any physician who has served as the primary treating physician for this injury may not be your QME. However, we will not replace a QME just because you saw him in the past for some other problem. The QME would only be excluded if he/she treated you for this injury. We will issue one new QME name to replace the primary treating physician. A QME is required to disqualify himself when he has served as the primary treating physician.

Note: The term "Primary" Treating Physician only applies to injuries as of 1/1/94. (IMC Reg. §31(d), §31.5(b)(1), 8 CCR §9785.5)

Complaints regarding QMEs - Frequently asked questions by injured workers

Q. How should I complain about a QME?

A. Any complaints should either be put in writing and sent to the IMC (attention Legal Unit) or you can make an anonymous complaint by calling our hotline at (800) 999-1041. We prefer that you give us your name and address or phone number so that we can reach you if we have a question.

Q. The QME panel physician did not issue his report and it's been over 2 months. What recourse is there?

A. First, we will check to see if the QME requested any medical tests or a consult with another physician which would delay the report. If an extension was not requested or if the extension requested was denied, you have the right to continue to wait for the QME report to be issued. We will issue a new panel if you do not wish to wait. In this case, either the carrier or you should contact the original QME and tell him not to issue his report as his bill will not be paid. (Labor Code 4062.5, IMC Reg. 38, 60 (b) (4))

Q. What should be done as it has been over 3 months and the QME has not issued the supplemental QME report requested?

A. If you have an attorney, contact that person for help. The QME should issue the supplemental report within 60 days if you don't have an attorney. You can contact us at the IMC or an Information and Assistance Officer for help.

Complaints regarding QMEs reports

Q. What can be done when the QME physician did not address all the issues?

A. If the DEU rating has not been issued, you may write to the QME and ask that he/she issue a supplemental report. Remember that 20 days prior to sending the letter to the QME, you must send a copy to the carrier. They have 10 days to object to the letter. If the rating has already been issued, you have 30 days to send a "Request for Reconsideration of the Summary Rating," (DEU form 103), to the DEU asking that the QME issue a supplemental report. Another option is to contact the Information and a Assistance Office and request their help in resolving the problem. (8 CCR §10164 and 10160 , IMC Reg. 35, Labor Code 4062.2 (e, f))

Q. What recourse do I have since I disagree with the QME's opinion on the permanent disability and my ability to perform the job?

A. 1991 - 1993 injuries: You may obtain a rebuttal (second opinion) QME panel from the IMC only when: 1. The original QME exam was performed by a panel QME physician and 2. The rebuttal is reasonable and necessary to resolve a disputed medical issue.

Prior to issuing the rebuttal panel, you must write to the claims administrator advising them why a rebuttal panel is being requested. Upon receipt of a copy of this letter, the IMC will issue a rebuttal panel if it is justified based on 1 and 2 listed above. The IMC will issue a panel with three new names.

If the carrier disagrees with the QME report, the Labor Code states that the carrier is to either provide benefits per the QME report or file an application of adjudication with the WCAB. (Labor Code 4061(k), 4064, IMC Reg. 32.7)

Injuries from 1/1/94 on: Before going through the QME process,a final disability report must be obtained from the primary treating physician. If either party disagrees with this report, they need to put their objections in writing, to the other party within 30 days of receipt of the report. They may then request a QME panel from our office. If you disagree with the QMEs findings, you are not entitled to another QME report at the carrier's expense.

However, if you agree with the treating physician's report, and the carrier agrees with the QME report , you may either negotiate a compromise with the carrier or contact Information and Assistance to discuss your options. (Labor Code 4061(d), 4062(a), 4062.9, 4064)

Complaints regarding ratings

Q. Whom do I contact if I disagree with the rating?

A. If either party disagrees with the DEU rating, they have 30 days to send the request for reconsideration of the summary rating to the administrative director (DEU 103). Use DEU Form 103. There are only four reasons to request reconsideration from the administrative director: 1) QME failed to address all issues 2) IMC procedures were not followed by the QME 3) QME failed to completely address all issues 4) Rating was incorrectly calculated. If it has been over 30 days since the rating was issued, or, if the reason you disagree with the rating does not fall into one of the four categories mentioned, contact information and assistance. (Regs. 8 CCR §10164)

Q. What recourse do the carrier or I have if we feel based on the QME's report that the QME needs to consult with a physician in another specialty and the QME does not feel a consult is indicated?

A. For injuries from 1/1/91 - 12/31/93: If either insurance carrier or you feel the QME has not consulted with a physician whose expertise is necessary for a complete and accurate evaluation, you may write to the IMC and request that the IMC direct the evaluator to consult with a physician in an appropriate specialty.

For injuries on or after 1/1/94: The QME is only allowed to consult with physicians who have treated you for this injury.

Q. I filled out DEU form 103 (request for reconsideration of summary rating) but have not heard anything. What should I do?

A. For information on the status of the case, call the Division of Workers' Compensation Rating Reconsideration Unit at (415) 975-2056

Problems with insurance carrier

Q. The insurance carrier has denied the claim. Can I see a QME?

A. If the carrier has completely denied every aspect of the claim/claims, you do not need to contact our office for a panel. You are entitled to see any QME (as long as he has not treated you for this injury). You should let the carrier know the name of the physician that you want to see; if there is a problem with the carrier authorizing the evaluation, call information and assistance. (Labor Code 4060)

Q. Why have my workers' compensation benefits stopped?

The only person that can tell you why the benefits have stopped is the claims adjuster for the insurance carrier. This is the person that has been providing those benefits. If you are having trouble contacting the adjuster, call information and assistance.

3. Why is the insurance carrier sending me back to see the same QME?

Contact the insurer to find out the reason. The carrier should not have contacted the QME without notifying you. It could be that the QME failed to address something in the initial report, or the treating physician thinks that you have gotten worse/better since the initial report, or the QME did not feel your condition was permanent and stationary when you were seen the first time or for a number of other reasons.

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