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FAQ, Medical Evaluations For My Case

What Happens During A Panel QME Or AME Evaluation?

A Panel Qualified Medical Examination is a medical legal evaluation performed by a state assigned doctor from the 3 doctor panel that was received in your case. this doctor reports on the legal issues in your case and is not a treating doctor.  If you are unrepresented, the only type of medical legal examination you can obtain is through a PQME, though you can ask you primary treating doctor for a medical legal report called a PR-4 report.

If you have an attorney, the attorney can have you seen by an Agreed Medical Examination instead of a PQME. This is a doctor that the parties agree to be the final say on the medical legal issues.  This agreement can be advantageous in very complicated cases (multiple dates of injury, denied injury, denied body parts, disputes about period or periods of temporary total disability due, etc.)  An AME is often a good idea because many of the PQME’s in our system now are new and are inexperienced dealing with the very complicated legal issues.  You cannot use an AME if you do not have an attorney.

Before the medical examination occurs, your medical records and any other documents relevant to your injury (such as your injury report, subpoenaed medical records, witness statements, video, etc.) can be sent to the PQME/AME evaluating doctor. The doctor will decide whether to review the documents before or after the examination. The insurance company will write a letter to the doctor explaining your injury, summarizing your course of treatment to date, and posing specific questions about your medical condition. These questions are used to frame the issues for the doctor. For example, the doctor may be asked his or her opinion about whether your current symptoms are related to your work accident, whether past injuries are causing your your current level of disability.  The insurance carrier is only responsible for the disability caused by the work injury and so the carrier will do what they can to reduce their liability by pointing out unrelated causes of disability.  If you are unrepresented, you must send the doctor all of records you want reviewed, to the claims examiner and doctor at least 20 days before the evaluation.

If you are represented by an attorney, the attorney should be writing a letter on behalf of the injured worker and review the insurance company letter for accuracy. You are entitled to review the carrier’s letter.  You should provide your attorneys office with any information you believe will be helpful for the correspondence to the evaluating doctor. It is not appropriate to bring documents to the evaluation and the doctor will likely refuse to review them.

During a medical legal evaluation, there is generally no expectation of a normal physician-patient relationship. This means that what you tell the doctor is not privileged or protected in any way. Your statements to the doctor could even be used against you in your workers’ compensation case. The same goes for observations the doctor makes. For example, if the doctor sees you walking normally from your car to the office, but then sees you grimacing with pain and favoring one leg in the office, he or she will make a note of that. You can bet that this inconsistency will show up in the doctor’s report, and the judge will take this into account when assessing your credibility. Be truthful and do not exaggerate. Make sure to tell the doctor about any prior accidents or injuries, especially those involving the same parts of the body.  In some cases the insurance company will be filming you during the course of the day (sub rosa investigation).  This video will likely not be used in the case until they see if you make truthful statement about your abilities to the doctor and during your deposition (see deposition FAQ and Youtube video).  Making false statement and withholding relevant information could be considered insurance fraud.

During the examination, the doctor will likely start out by asking you about how your injury happened, what your relevant medical history is, and the course of your treatment so far. To prepare, you may want to go over your notes and review the timeline of what happened between your accident and the date of the evaluation.  You should be prepared to tell the doctor how your activities of daily living (abilities to dress yourself, cook, clean, go about your day) have been affected by the injury.  The more thorough you are the better. 

You should ask questions about your condition and any potential treatment options that might help. You should provide any information you feel is helpful to the doctor in learning about the history and injury. If the doctor will be giving you a permanent impairment rating, you should ask how the doctor calculates the rating. You should also be sure to tell your doctor about any areas of your body that are still in pain and about any activities that you still have difficulty performing. Once your physical examination is done, the doctor will write a report and send it to all parties. Your attorney should send you a copy copy of this report upon receipt. Read it carefully so that you can point out any factual mistakes in your treatment or medical history.  Keep track of how long the evaluation lasts. Does the report reflect the accurate amount of time you spent with the doctor?  Keep in mind that doctors are going to make mistakes, and sometimes will make a lot of mistakes when it comes to the history of the injury and your lifetime of treatment. Not all mistakes are relevant to your case and are worth delaying the case to fix. It is important that you consult with your attorney, who will be able to tell you the next steps. Often the case will be ready to make a settlement demand after a medical legal report, but just as often, there is a lot more to be done.