Second Medical Opinion in Your Workers’ Compensation Case

By Juan Flores

After an injured worker has filed a workers’ compensation case, it is likely that they will undergo an evaluation by a Qualified Medical Examiner (“QME”) or an Agreed Medical Examiner (“AME”). This process is called the medical-legal process. A QME is designated after both the Applicant and the Defense have had an opportunity to strike one of the doctors from a panel list of three doctors that is issued by the Workers’ Compensation Medical Unit – the remaining doctor not struck by either party is then designated as the QME. An AME is a doctor that is agreed to by the Parties to act as the medical evaluator in the case.

The role of the AME/QME includes various aspects that affect the monetary value of your workers’ compensation case. The AME/QME’s responsibilities include determining periods of temporary total disability, permanent disability impairment, and the need and extent of future medical treatment. The AME/QME is able to consider the entire medical records for treatment you received as a result of your work injury, and any medical records provided to them that precede your work injury. Using this evidence, the AME/QME will make determinations that will affect the value of your case including whether there is causation (whether the workplace incident actually caused your injury to a specific body part) and apportionment (whether your current condition or permanent impairment to a specific body part is fully, partially, or not at all related to the workplace incident).

After considering the evidence and once the AME/QME determines that you have reached maximum medical improvement, they will issue a permanent and stationary report where they will provide permanent disability ratings, ranging from 0% to 100%. Each of these percentages represent a different monetary value (i.e. 3% is valued at $2,610, 13% is valued at $12,252, and so on.) Furthermore, the AME/QME will determine the periods of temporary total disability benefits that are owed to you (between 0 and 104 weeks).

There are times when an AME/QME will issue a report with a very low or no permanent impairment rating and little to no temporary disability benefits owing. This severely impacts the value an Applicant’s workers’ compensation case. In such situations, an Applicant is not without recourse. An Applicant can request, and is entitled to, a report by their treating physician addressing the issues that an AME/QME does.

Once an AME/QME issues a final report, an Applicant has a right to obtain what is known as a PR-4 report. A PR-4 is a permanent and stationary report prepared by the injured worker’s own doctor – the doctor that has treated the Applicant for their industrial injury and has likely had more face to face time with the Applicant than the AME/QME has. The right to obtain a PR-4 report before a case can be fully resolved comes from Labor Code § 4061(i) which states that “no issue relating to a dispute over the existence or extent of permanent impairment and limitations resulting from the injury may be the subject of a declaration of readiness to proceed unless there has first been a medical evaluation by a treating physician and by either an agreed or qualified medical evaluator” (emphasis added.)

Thus, an Applicant has the opportunity and right to obtain a report from their treating physician that will essentially serve as a second opinion regarding, inter alia, their permanent impairment rating, periods of temporary total disability, and future medical treatment. Although there are times that there may not be much of a difference between the AME/QME and the treating physician, there are times when a treating physician’s report may substantially increase the value of an Applicant’s workers’ compensation case because it may be more substantial or because it will help in persuading the AME/QME to change their opinion.