Resolving Disputes

1. If you dispute denial of benefits - You can appeal to the Workers’ Compensation Appeals Board. This is where workers’ compensation judges hear cases and decide on problems and disputes. If a problem can’t be resolved through discussions with the claims administrator, IIHC can provide an attorney, who can request a hearing and represent you before the judge. If you disagree with a decision of a workers’ compensation judge, you can request reconsideration of the judge’s decision by a seven-member Appeals Board.

2. If you disagree with doctor about necessary treatment - IIHC will refer you to an attorney who can take you through the different step that are taken if you disagree with your treatment plan, depending on whether your employer is an MPN, HCO, or neither.

If your employer has an MPN:

1. You can switch doctors within the MPN.

2. If you disagree with the second opinion, you can get opinions from up to 2 more doctors within the MPN. You must be seen by these doctors within 60 days after you receive the list of doctors from your employer.

3. If you disagree with all of those opinions, you can obtain an independent medical review arranged by the DWC. If after that review, the doctor agrees with you, you can get treated by a doctor outside the MPN.

If your employer has a contract with an HCO:

1. You can switch to a new doctor within the HCO. Your employer must give you a choice of doctors within 5 days after you request the change.

2. If you disagree with the second opinion, you can get a third opinion within the HCO.

3. If you disagree with the third opinion, you can ask the HCO to help resolve the disagreement. The HCO must reach a decision within 30 days.

If you employer does not have an MPN or HCO:

1. You can switch to a new doctor.

2. If you disagree with the new doctor’s treatment plan, you can send a letter to the claims administrator about the disagreement within 30 days. An attorney can help you draft this letter.

3. If you disagree with a medical report or disagree with a decision to deny treatment, you have the right to get a medical evaluation by a qualified medical evaluator (QME). QMEs are doctors who are certified by the DWC to conduct medical evaluations in workers’ compensation cases.

• If you don’t have an attorney, within 10 days after the claims administrator sends you the instructions, you must select the medical specialty of the QME and request from the DWC a panel (list) of three QMEs. Within 10 days after the DWC sends you a panel, you must choose a QME from the panel, make an appointment to be examined by the QME, and tell the employer of your choice and appointment time. If you do not meet these deadlines, the claims administrator will choose the doctor you must see.

• To make it easier on yourself, contact IIHC. An attorney will help come to an agreement with the claims administrator on a doctor called Agreed Medical Evaluator (AME). AMEs are not required to be certified by the DWC.

• If an agreement on a doctor cannot be reached, your attorney or the claims administrator may request from the DWC a panel (list) of three QMEs. Your attorney and the claims administrator may agree on someone from this panel. If agreement still cannot be reached, your attorney and the claims administrator may each strike one name from the panel, and the remaining QME will conduct the evaluation.

• If you were injured before 2005 and agreement on a doctor cannot be reached, your attorney will select a QME.

 

Related Topics:

• California Employees Rights

• California Laws

• Benefits (Compensation)

• Predesignating a Physician

• Filing a Claim

• Resolving Disputes

• Workers’ Compensation Facts

• California Workers Comp FAQs