Any worker struggling with a job-related health condition should be able to claim workers’ compensation insurance benefits. The benefits available include full health coverage for necessary treatment and disability benefits if you have to miss work.
Unfortunately, some workers who apply for benefits don’t receive them because their employer wants to deny their claim. A common reason companies give for challenging workers’ compensation claims is the assumption that the worker got hurt outside of work.
What happens in that scenario?
Doctors help resolve the dispute
The California Division of Workers’ Compensation sees enough complex worker injury cases every year to have many disputed claims annually. The state has procedures in place for the most common kind of disputes, including allegations that a worker didn’t suffer their reported injury at work.
California certifies certain doctors as qualified medical evaluators (QMEs). These medical professionals have the authority to make determinations in workers’ compensation cases. When there is a dispute about the origin of an injury, the worker or their employers can request a QME to resolve the dispute.
The state will provide the worker with a list of three available QMEs who can evaluate them, and they will have to select one and undergo a medical exam. The list will be random, so the worker may need to travel. Compensation for that travel can be part of their overall claim.
The testing performed by the QME will determine whether the injury likely results from the worker’s employment or not. Their report will influence the next steps necessary for the workers trying to get benefits.
Understanding the complex rules for workers’ compensation benefits can help those dealing with a contested claim.