[CA] [CA] Should I pursue workers’ comp and request a Qualified Medical Examiner?
I was out on short-term disability from 11/19/24 to 3/24/25. I returned to work and re-injured myself. I finally got disability approved yesterday but need advice on whether I should pursue workers’ comp, as I only have a week to request a Qualified Medical Examiner (QME).
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You’re facing a denied workers’ compensation claim — likely based on a pre-existing condition defense. That usually means the insurer claims your injury didn’t happen because of your job, or that it existed beforehand.
However, since your job duties (heavy lifting, squatting, etc.) aggravated your condition, you may still qualify for workers’ comp — especially under California law, which recognizes the aggravation of a pre-existing condition as a valid basis for benefits.
Should You Pursue Workers’ Comp and Request a QME?
Yes, absolutely.
If you’ve only got a week left to request a QME (Qualified Medical Evaluator), do it right away. The QME process lets you challenge the denial and get an independent doctor’s opinion.
You’re essentially saying, “I disagree with the denial and want another medical expert to weigh in.”
Since you’re on light duty (ending soon), workers’ comp could protect your income and medical treatment options if your condition worsens or you’re removed from duty.
Here’s What You Should Do:
1. Request the QME Panel Immediately:
- You only have 10 days from the denial to request it.
- Use DWC Form 105 and submit it to the DWC Medical Unit.
- You’ll receive a list of three doctors to choose from.
2. Document Everything:
- Describe your job duties (lifting, squatting, climbing, etc.).
- Note when symptoms began and how they worsened.
- Explain how work aggravated your bladder prolapse and incontinence.
3. Address the Conflict of Interest:
- If your surgeon denied the claim, that’s worth raising.
- QMEs exist to provide an objective opinion, especially when the treating doctor has a conflict.
4. Prepare for the QME:
- Provide detailed job descriptions and medical history.
- QMEs may not fully understand pelvic organ prolapse, so your explanation matters.
- If the QME supports you, it can significantly strengthen your case — even if the insurer pushes back.
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I was out on short-term disability from 11/19/24 to 3/24/25. I returned to work and re-injured myself. I finally got disability approved yesterday but need advice on whether I should pursue workers’ comp, as I only have a week to request a Qualified Medical Examiner (QME).
Lexi, Chatbot
Have you already filed a claim with your employer or the relevant insurance provider regarding your disability or workers’ compensation?
Yes, it was denied.
Lexi, Chatbot
Is there anything else the lawyer should know before I connect you? Rest assured they’ll be able to help with your workers’ compensation issue.
Yes.
Legal Eagle
Hello! Legal Eagle here — I’m an attorney specializing in this area of law, and I’m happy to help you with your situation.
What specific reasons were given for the denial of your initial workers’ compensation claim?
Pre-existing conditions.
Legal Eagle
Okay, thanks! Just a few more questions. Were there any additional medical records or evidence that could support your case for workers’ compensation?
Yes. I believe it’s due to my job functions — that was the initial cause. However, with limited doctor time, we focused on fixing the injury, not the cause. So, I didn’t file for workers’ comp in the beginning.
Legal Eagle
Got it! That makes sense. Were there any other details you’d like to add before I answer your question?
Also, the doctor who gave the assessment for workers’ comp was my surgeon. That seems like a conflict of interest.
I had a prolapsed uterus, prolapsed bladder, and incontinence. The uterus was removed via hysterectomy, and my bladder was lifted with laparoscopic surgery. My prolapsed bladder is back, which worsens my incontinence.
I’m a communications technician, so I do a lot of heavy lifting and squatting.
I’m currently on light duty until June 19, but it will end soon, and I’m not sure how my company will handle it since light duty usually isn’t granted long-term.
Legal Eagle
You’re facing a denied workers’ compensation claim — likely based on a pre-existing condition defense. That usually means the insurer claims your injury didn’t happen because of your job, or that it existed beforehand.
However, since your job duties (heavy lifting, squatting, etc.) aggravated your condition, you may still qualify for workers’ comp — especially under California law, which recognizes the aggravation of a pre-existing condition as a valid basis for benefits.
Should You Pursue Workers’ Comp and Request a QME?
Yes, absolutely.
If you’ve only got a week left to request a QME (Qualified Medical Evaluator), do it right away. The QME process lets you challenge the denial and get an independent doctor’s opinion.
You’re essentially saying, “I disagree with the denial and want another medical expert to weigh in.”
Since you’re on light duty (ending soon), workers’ comp could protect your income and medical treatment options if your condition worsens or you’re removed from duty.
Here’s What You Should Do:
1. Request the QME Panel Immediately:
- You only have 10 days from the denial to request it.
- Use DWC Form 105 and submit it to the DWC Medical Unit.
- You’ll receive a list of three doctors to choose from.
2. Document Everything:
- Describe your job duties (lifting, squatting, climbing, etc.).
- Note when symptoms began and how they worsened.
- Explain how work aggravated your bladder prolapse and incontinence.
3. Address the Conflict of Interest:
- If your surgeon denied the claim, that’s worth raising.
- QMEs exist to provide an objective opinion, especially when the treating doctor has a conflict.
4. Prepare for the QME:
- Provide detailed job descriptions and medical history.
- QMEs may not fully understand pelvic organ prolapse, so your explanation matters.
- If the QME supports you, it can significantly strengthen your case — even if the insurer pushes back.
So I would need to find legal representation. Thank you for your advice. I wasn’t sure if I should pursue the workers’ comp or make it a disability relapse.
Legal Eagle
Correct!
Here are some resources to find representation or legal aid:
You can also check local law schools or Yelp.com for reputable workers’ comp attorneys.
Most attorneys in workers’ comp take cases on a contingency basis — meaning no upfront cost.
You can also come back here and ask me questions along the way to keep your costs low.
Thank you.
Legal Eagle
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