Workers' Compensation Denied Cases and PQME Process
Hi everyone, Coleen Pratt here. This video is going to talk about what to do when your case is denied and what procedures take place after we learn that the insurance company has denied your claim.
For starters, the insurance company has 90 days to accept or deny your claim. The 90 days runs from the time the insurance company receives the claim form either filled out by you or from our office to accept or deny your workers' compensation claim. Within that time period, you might receive a letter that says your claim is on delay status. This means the insurance company is gathering information and doing their investigation to determine whether your claim is compensable or not.
At the end of the 90-day period you'll receive a letter, as will our office, indicating whether the insurance company is accepting liability for your claim or denying liability for your claim. There could be several reasons for a denial. It could be a factual basis. In other words, the insurance company or the company is saying that the claim was never reported or the injury didn't happen. Or it could be a medical reason that there's no medical evidence to support causation between your injuries and your work duties.
If your case is denied for medical reasons, then our office will begin what's called the "panel qualified medical evaluation process." This is something our office will handle and it begins with us asking for a three-doctor panel from the state of California. Once the panel is received, our office will strike a doctor off the list, the insurance company will strike a doctor off the list, and it's the third doctor that will be setting up the appointment with you in order to evaluate whether your injuries are work-related.
The panel qualified medical evaluator will discuss not only causation (in other words whether your injuries are related to your job) but we'll also discuss other issues such as periods of temporary total disability and also permanent disability if the doctor decides your condition has stabilized.
Our office will receive the medical report within about 35 to 40 days from your PQME appointment, and we will review it thoroughly and discuss it with you if necessary. If the PQME report doesn't meet certain guidelines or doesn't qualify as substantial medical evidence, rest assured our office will take action.
Also, if during the PQME panel process you're not receiving benefits from the insurance company and your doctor has you unable to work at this time, be sure to apply for EDD state disability right away. Have your doctor certify you, and you can either apply online or you can get the forms from your doctor's office.
Thanks for watching and make sure to check out the video on how to prepare and what to expect at your upcoming PQME exam. Thank you.