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Insurer/Claims

Workers Comp insurance in California is mandatory for all employers who usually buy policies through insurance brokers. When a claim is submitted the insurance carrier usually provides a Medical Provider Network (MPN) for examination and treatment of the employee at an approved and convenient location. Most cases will end there and the employee will return to work. However, a dispute regarding the diagnosis and/or treatment may arise between the employer and employee, and the insurer, as well as attorneys may become involved in adjudicating the case.

An insurer might contest a workers' compensation claim over issues such as whether the injury was sustained on-the-job or how much in benefits should be paid, a dispute may require the assistance of an attorney specializing in this area.

When the insurer and/or claim administrator for the employer disagree with the physician report the employee’s injury or treatment, the next step is to contact a Qualified Medical Evaluator (QME). The QME is a physician who meets additional educational and licensing requirements, and is able to evaluate the recommended treatment and adjudicate the compensation issues. If the claimant’s attorney and the employer’s claims administrator agree on a qualified doctor to resolve medical disputes, this doctor is called an Agreed Medical evaluator (AME).