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  1. #1
    Join Date
    Oct 2009
    Posts
    2

    Question Zero Percent QME Rating

    I have a back injury which occurred in 9/2008. I was labeled P&S earlier this year, and received a zero percent rating (whole person) from the panel QME in August 2009. His explaination was that the injury did not fall in line with the AMA Guides. My permanent and stationary report from the chosen primary doctor lists me as 14% (whole person) and has a different diagnosis than the QME.

    Does anyone know what my next course of action should be? I have avoided retaining a lawyer, because thus far the insurance company has been fairly reasonable, but now they are trying to settle at 7% because of the 0% rating from the QME. Is it too late to dispute the QME's report or can I ask for a supplemental report?

    I should also mention that the local state Worker's Comp office has been next to no help at all. I have called them several times for advice, and each time they tell me to call my insurance adjuster.

    Thanks!

  2. #2
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,021

    Default Re: Zero Percent QME Rating

    PQME reports are supposed to automatically go to DEU for review...and you can't do anything until their rating issues. After that, IF you have medical evidence that was not available at the time of your PQME evaluation, you can request a supplemental. Not just because you disagree with the report/rating.

    Barring that... get your PTP to write a med/legal report to refute the QME findings... and file a DOR for hearing with a WCAB judge.
    As the carrier has a report that indicates a 0% PD/WPI... they are being magnanmous... they don't have to offer squat.

  3. #3
    Join Date
    Oct 2009
    Posts
    2

    Default Re: Zero Percent QME Rating

    I checked with the DEU, and they have no record of my QME report being submitted. They said to call the insurance adjuster because they are supposed to submit it with the proper paperwork. I called the IA and left a message, so hopefully they call back soon. Is it allowable for me to request my rating from DEU, or does it have to go through the insurance adjuster?

    Also, they have had the QME report since August. Is there a timeframe that the Insurance Company has to comply with in submitting the QME report to DEU?

    Thanks for the help, just trying to get my facts straight

  4. #4
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,021

    Default Re: Zero Percent QME Rating

    The rules for medical/legal evaluations...PQME/AME are here http://www.dir.ca.gov/t8/ch1a3.html.

    There are timeframes for the carrier to dispute a PQME report, obviously they are not going to dispute a 0% rating. You could move this along by filing a DOR for a rating MSC/mandatory settlement conference. The DEU would provide a rating at the hearing.

    I was under the impression the PQME was supposed to submit the report to the DEU when it was provided to the parties...you and the carrier. I'd have to go back and read the rules at the link above...but, I'll let you do that first.

  5. #5
    Join Date
    Jan 2009
    Posts
    63

    Default Re: Zero Percent QME Rating

    Does the PQME report have a mailing address from Fresno? If so, they are notorious for that. But the good thing is that they are easy to rebut if you're PTP is willing to do that and has a good understanding of the Guides.

    I just had a report like that overturned. PQME gave 0%, rebuttal was issued, attorney went to court and authorized back surgery.

    All is not lost.

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