If you were injured at work, the benefits of having a workers’ compensation lawyer on your side cannot be understated. Although it is your right under California law to receive workers’ compensation benefits if you suffered an injury while on the job, your employer and the insurance companies may not be forthcoming with the kind of benefits you and your family need to ensure your quality of life.
Workers’ compensation laws can be extremely complex and difficult to navigate. Sometimes, a worker’s injuries may not be fully expressed in medical reports ultimately used by insurance companies to determine what benefits will be dispersed. Hiring an experienced and qualified San Francisco workers’ compensation attorney can help you dispute the findings of these reports.
Disputing Workers’ Compensation Necessary Treatment With HCO or MPN
After an accident, workers’ compensation injury victims will visit one of two medical providers for evaluation of necessary medical treatment: Health Care Organization (HCO) or Medical Provider Network (MPN). Depending on which organization examines treats the victim, different steps may need to be taken in order to receive a second opinion on the injury.
Challenging HCO Medical Evaluations
HCOs are workers’ compensation organizations certified by the State of California Division of Workers’ Compensation providing healthcare to injury victims. These medical providers must meet certain health care access and delivery standards.
Injured workers disagreeing with their HCO’s medical evaluation for necessary medical treatment are allowed to see another physician within the HCO network. If an injured worker disagrees with his or her doctor’s evaluation, the matter may be adjudicated by an expedited grievance procedure with the HCO.
Challenging MPN Medical Evaluations
An MPN is a collection of healthcare providers organized by insurance companies providing treatment to workers injured on the job. California’s Division of Workers’ Compensation also approves the providers in this network.
Workers wishing to challenge an MPN doctor’s evaluation for necessary medical treatment may seek second and third opinions from other physicians within the MPN. Employers and insurance adjusters must provide the injured victims with information on how to do so. There are strict time deadlines when victims must make appointments to see these other doctors or they may not be able to seek a second or third opinion.
Workers’ Compensation Injury Victims Not Receiving Treatment from HCO or MPN
Injured workers not receiving treatment from an HCO or MPN have a different appeals process to challenge medical reports. First, a letter must be sent to the insurance adjuster handling the claim challenging the evaluation. Injured workers retaining legal counsel must send this letter within 20 days of receiving the medical evaluation.
Next, work injury victims must receive a medical evaluation from another doctor. Having an attorney in this situation can be especially important. The workers’ compensation attorney and the insurance adjuster must concur on an agreed medical evaluator (AME). An AME is a doctor not certified by the California Department of Workers’ Compensation.
If an AME cannot be agreed upon by injury victim’s attorney and the insurance claims adjuster, the Department of Workers’ Compensation will provide a list of three qualified medical evaluators (QME). If no agreement on the examining physician can be reached by the two parties, each side may strike one doctor from the list and the remaining physician will perform the examination.
The AME or QME will create a medical-legal report detailing your medical condition. You may only be able to see one AME or QME so your workers’ compensation attorney will need to choose the right one to ensure you receive a fair examination as this will help determine the benefits you and your family receive.
Why Is Having a Workers’ Compensation Attorney Important?
Having a San Francisco workers’ compensation attorney to handle your medical evaluation is important because there are time deadlines, appeals processes, and legal pitfalls which may impede the disbursement of workers’ compensation benefits. Retaining an attorney from the onset of your workers’ compensation claim can be one of the most important decisions you make to protect you and your family.