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What Are Medical Legal Evaluators, and Why Are They Important?

A Medical Legal Evaluator is an individual who is a licensed healthcare provider (such as a registered nurse or a physician) who acts as a neutral third party when evaluating what kind of benefits a person should receive for their injury or illness. A qualified medical evaluator, QME for short, is often used in cases of workers’ compensation. Read on to learn more about how QMEs are used in Workers’ Compensation cases and why they are important. 

What Is Workers’ Compensation?

Workers’ compensation refers to an insurance program that provides medical care and/or cash benefits to workers who have become injured while on the job or as a direct result of their job. Suppose the employee can still work but the injury or illness prevents them from making the same amount. In that case, workers comp can make up two-thirds of the difference in wages. If applicable, the employee may also return to work on alternative duty until fully healed. 

Workers’ Compensation insurance is not always mandatory, but most states require that businesses carry some kind of workers’ compensation insurance that is not paid for by employees. The fees are paid under the direction of the Worker’s Compensation Board of that state. This state agency both manages the insurance payments and processes claims from employees seeking workers’ compensation. They also can intervene in workers’ compensation cases to determine the amount and duration of cash benefits or medical care benefits. 

Workers’ compensation is not like a legal case where one party is determined to be “at fault,” and the other uses it. In Workers’ Compensation, the amount is predetermined and is not increased or decreased by “fault” on the part of the worker or the employer. However, there are cases in which an employer can automatically deny benefits, such as if the injury is a result of intoxication on the part of the worker or if the injury is determined to be self-inflicted or intended to hurt others, then workers’ compensation benefits may be denied

Sometimes employers or insurance companies dispute workers’ compensation claims– they may claim the injury or illness is not job-related. When Workers’ Compensation payment is disputed by the employer or insurance carrier, the case may go to court to determine if benefits should be paid out or not. 

What Role Does a Medical Legal Evaluator Have In Workers’ Compensation?

Now that we know what Workers’ Compensation is and how payment works, we need to know what role Medical Legal Evaluators or QMEs play in the process. When a workers comp case is filed, it is required to come with a report from a medical professional. Generally, when someone is injured on the job, they go to their primary care physician for treatment of their injuries or illness, and the primary care physician can give their expert opinion on the patient’s injuries or illness. 

At this point, a Medical Legal Evaluator is usually assigned to the case. This person is either a Qualified Medical Evaluator (QME) or an agreed medical evaluator (AME.) Their job is to act as an unbiased medical third party to examine the patient and give their official medical opinion on the patient’s injuries or illness. A QME can also order additional tests and X-rays to further evaluate the patient for their final report. This report can be used in court either in support of the employer to the injured party. 

Medical Legal Evaluators are especially important in cases of Workers’ Compensation where parties disagree on doctors, illnesses, or the extent of the injury.

Other Medical Legal Evaluation Services

While often used in Workers’ Compensation cases, that is far from the only thing that Medical Legal Evaluation services are used for. A QME can be used to determine Subsequent Injury Trust fund benefits and Disability benefits qualification and payments. They are also useful in personal injury cases or to determine fitness for duty. Basically, any legal situation that requires a third-party medical evaluation can benefit from using a QME. 

Legal Medical Consulting in Dallas TX 

If you are looking for medical legal evaluations in Texas, consider Legal Medical Consulting. Dr. McNew and his team have decades of experience in the Medical Legal world, from representing hospitals to private patients. A qualified medical evaluator must be a healthcare provider who meets educational and licensing requirements, as well as passes a test, and receives ongoing education. But not all GMEs are created equal, and when it comes to something as important as your health, you want the best. So call Legal Medical Consulting or check out their website today! 

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