Home > QMEs > The Devil in the Medical Report Details

The Devil in the Medical Report Details

A recent writ denied case highlights the importance of diligently reviewing and thoroughly understanding the medical basis for the opinions of evaluating physicians.

In the case of Daniels v. Workers’ Compensation Appeals Board, defendant petitioned for reconsideration of the Workers’ Compensation Judge’s order and award of 70% permanent disability for applicant’s injury.

The WCJ awarded applicant 65% PD for the orthopedic spine injury and 10% for his alleged psyche injury, combining the two for a 70% award.  One should note that at 70% permanent disability, applicant becomes entitled to a pension, so there is a big step between 65% and 70%.

Because this is a 2002 injury, each party retained their own Qualified Medical Evaluator instead of going through the panel process.  Defendant’s psyche QME found no ratable psyche injury, based on two evaluations and using the 8 work functions of the 1997 rating schedule.  Applicant’s psyche QME, to the surprise of no one, found impairment in all eight of the functions.

However, at trial, cross examination of the applicant revealed that there was little to no impairment to any of the 8 work functions associated with the alleged psyche injury.

Although the WCJ found that the opinions of the defendant’s QME were “better reasoned and more persuasive” than those of the applicant’s QME, using the “range of evidence” in her instructions to the DEU the WCJ achieved a 10% psyche rating, coming to a total impairment rating of 70%.

The Workers’ Compensation Appeals Board granted defendant’s petition for reconsideration, reasoning that applicant’s QME’s report did not constitute substantial evidence, and therefore the WCJ was mistaken in relying on his report.

Often times enough, practitioners in the world of California’s Workers’ Compensation hesitate to roll up their sleeves and deal with the dirty details of medical reporting.  This isn’t always a case of laziness – sometimes there is concern for billing needless hours in a seemingly futile (or slam dunk) case.  The details of the medical reports are where the fighting needs to take place – skipping to the conclusion section will also skip over the best arguments and the best chances of defeating or defending a medical report.

Categories: QMEs
  1. October 12, 2011 at 12:49 pm

    Excellent insights. Unfortunately the vast majority of reports we review fail to meet standards defined for IMEs (including QME and AME reports). These standards are specified in the AMA Guides in Section 2.6 and Principles of Assessment in the individual chapters. In addition, the Guides Newsletter has published articles defining standards. It is often useful to have a medical expert review a report to assist attorneys, claims professionals, and other stakeholders determine if the conclusions are supportable. Unfortunately many reports, when carefully analyzed, would not meet standards of substantial evidence.

    Chris Brigham, MD, Impairment Resources, LLC (www.impairment.com)

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