Winning the Battle of the Medical Opinions
Before you are going to get surgery covered by workers’ compensation insurance, you are often asked to go for an Independent Medical Examination. This is an evaluation by a physician that the insurance company sends you to, at their expense, to get a medical opinion about the cause and/or treatment for your injury.
Even with the best of intentions by all of the physicians involved, there is still frequently a disagreement about the recommended course of treatment. If your treating physician recommends surgery, and you want to go through the procedure, you hope for the best that IME physician will agree, but prepare for the possibility that he or she will not.
How can you position yourself the best to win the battle of the “experts” and have your surgery covered? First, be sure that the expert you are putting out there is qualified and credible. The insurance company is likely to hire someone who specializes in the particular area your issue involves. If your doctor does not have much experience in this type of procedure, or is a general physician rather than a specialist, then the recommendation may be given less weight. Credibility is also key. The reputations of the doctors can sway the opinion one way or the other. Honestly, a lot of lawyers and insurance companies screw this part up by sending workers to “hired guns” that are known to say whatever needs to be said, not necessarily the truth.
Second, if your physician has the experience and expertise to give the opinion for surgery, be sure that he or she can back it up. A recent Illinois workers’ compensation case was lost largely because the treating physician’s surgery recommendation was made without the necessary specifics to support it. There was no rationale behind the decision, other than to say that if physical therapy did not work then this surgical procedure should be tried.
The IME physician was detailed and convincing in his opinion that surgery was not necessary under the circumstances. He gave specific medical reasons why he did not think that this was the right procedure. He also was detailed in his discussion of the worker’s risk factors that would make the surgery much less likely to be successful. In the end, the insurance company’s physician was far more credible and convincing and surgery was denied.
When you want to get your surgery covered, it can be a frustrating process to have to fight to have your opinion accepted. But with a good lawyer in your corner, and the right medical evidence and support to back you up, you have a good shot at winning the battle of the medical experts, if your case comes to that.
We are workers' compensation attorneys that help people with Illinois work injuries anywhere in IL via our statewide network of attorneys. Contact us and we will answer your questions or find the right lawyer for your situation.
