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Thread: AME Denial

  1. #1
    Join Date
    Mar 2008
    Posts
    93

    Red face AME Denial

    I just received a letter from the ic stating that the cysts and the kidney stones I have are being denied .

    I have an ame that stated I needed to be seen by the urologist before he could report that it is industrial.
    In his report he states it is industrial so how can they do that with an ame?

  2. #2
    Join Date
    Dec 2006
    Posts
    2,165

    Default Re: Ame Denial

    Feelin, I think what is happening here is that, although your AME thinks that the cysts and kidney stones may be industrial-related, that AME has referred you out to a SPECIALIST, a UROLOGIST.

    Because these kidney issues are NOT in your AME's area of expertise, he will DEFER to the UROLOGIST'S final opinion. The Urologist will perform an evaluation of you, render an opinion and recommendations, and send the report back to your AME. Your AME will then INCORPORATE the Urologist's opinion into a supplemental report.... Until then, the IC is denying/disputing those injuries, which is within their rights to do. Just as it would be YOUR right to dispute the AME's findings/recommendations if it were unfavorable to YOU.

    You must realize Feelin, that although in the MAJORITY of cases whatever the AME "opines" is usually binding, EITHER PARTY can still DISPUTE the AME's opinion, INCLUDING THE IC.

    As I have posted previously to you at great length, it IS going to be an "up-hill battle" for ANY party who is disputing an AME's opinion..... That is when there will either be a DEPOSITION of the AME, and possibly, an Expedited Hearing or a TRIAL, and ULTIMATELY, the JUDGE will be the one to resolve the disputed issues....based on the veracity and "SUBSTANTIAL EVIDENCE" of the medical reports and evidence....

  3. #3
    Join Date
    Oct 2006
    Posts
    9,108

    Default Re: AME Denial

    your post is contradictory
    your AME can't say both: "it is industrial and you need to see another doctor before I can determine whether it's industrial."
    I can see how the carrier would deny such a confusing medical opinion. No matter what the doctor said after this I'd depose them. it looks like a weak doctor with a weak opinion.

  4. #4
    Join Date
    Mar 2008
    Posts
    93

    Wink Re: AME Denial

    sorry I said it wrong he thinks it is industrial but needs urologist to confirm .

  5. #5
    Join Date
    Dec 2006
    Posts
    2,165

    Default Re: AME Denial

    Then the IC will continue to DENY THE KIDNEY issues, PENDING the report/opinion from the UROLOGIST. The AME has CLEARLY deferred CONFIRMATION of his opinion that the kidney issues are indeed industrial in naure, TO THE UROLOGIST.

    So, you will have to WAIT until you are EVALUATED by the Urologist, and the Urolgist sends his report back to your AME to INCORPORATE the Urologists findings into a supplental report.

    IF the UROLOGIST does indeed CONFIRM that the kidney issues ARE industrial in nature, then the IC/CA "should" accept the kidney claim......

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