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The role of independent medical evaluations in workers’ compensation cases

On Behalf of | Oct 25, 2021 | Workers' Compensation, Workers' Compensation Process |

Independent Medical Evaluations, or IME’s, are an important tool for insurance companies and other responsible parties to establish the legitimacy of claims by people who have been injured in an accident. Because cash settlements can be substantial, especially where the victim has sustained serious injuries, these parties want an objective examination to check on whether the extent of injury is as bad as claimed.

In California, the workers’ compensation system has an independent medical review (IMR) process to resolve differences of opinion that arise in the medical care of injured workers. The purpose of the IMR is to avoid the court system, which is time-consuming and expensive.

In workers’ compensation cases, the IME is a major part of the review, not only in determining the extent of treatment necessary but also when you must return to work. For San Diego area workers, understanding your rights when you have a legitimate claim is crucial when it comes time for the IMR to review your case.

Workers’ compensation in California

Workers’ compensation in California is a no-fault system in which a worker who has been injured on or related to the job can receive benefits without having to prove that the employer was liable for the injury. To determine the necessity of medical care within the workers’ compensation system, there is a utilization review process that may delay or deny treatment. When this happens, the worker can ask for a review of the decision through IMR.

Unfortunately, this process can cause delays in needed medical treatments to injured workers and a claim denial requires an appeal to overturn it, which will mean additional delays in needed treatments.

What happens in a request for an IME

The purpose of an IME is to obtain a neutral assessment of the injuries sustained in many types of accidents in order to assess the extent of compensation required to heal the individual. As there is a perception that the primary care provider might have a bias toward their patient, insurance companies want a second opinion that will verify that:

  • The patient sustained injuries
  • The injuries are as serious as claimed
  • The claim is not for another malady

In workers’ compensation cases, the insurance company usually chooses the doctor and pays for the service. The doctor and insurance company will have access to all the worker’s medical records or statements regarding the accident claim, and as there is no client confidentiality, the doctor will include statements or observations in the final report that may negatively impact the worker’s claims.