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San Diego, CA |

I got injured last year in December( had surgery and claim has been accepted ). and so mid February I got neck pain, which I told to the first doctor and checked in questions paper by the doctor before the back surgery , who my employer has selected for me. At the End of February I filed a claim for my neck pain which had been denied. Then I filed a QME form 105 and sent to DWC- Medical Unit. My questions are:(I am restricted work released)
1- In that case, can the workers´Comp continue to pay me or not?
2- Has a QME form 105 a time limit which can cause to bar me from my benefit.
3- Should I wait for QME or should apply for a hearing
4- My employer looking and spying me to find something to fire me. He ask and search . many people told me with whom my employer talked to.What can I do in

I am restricted work released but dont work because my employer said, we havent light duty for you know. would be considered the neck pain in the future as pre-exist. if my claim has been not accepted (QME 105)

Attorney Answers 3


(1) Can Workers' Comp continue to pay? Insurance does NOT pay on a Denied Claim. YOU MUST PROVE at Trial that the new injury is an Industrial INjury before the Insurer must pay... you prove that with a report by the Qualified Medical Evaluator (QME), then file for the AOE/COE Priority Conference, then set it for trial.

(2) Has a QME for 105 form time limit which can cause to bar me from my benefit?? Yes, and no. When the Panel of 3 doctors is mailed from the Medical Unit in Oakland, you have a time limit to select a QME appointment and notify the Insurer of that appointment;so, yes, there is a time limit.

If you fail to get the appointment with a couple of weeks of receiving that list of 3 doctors, the Insurer will pick the worst guy on the list.

If a bad QME writes a QME report stating there is no industrial injury...if the medical evidence shows there is no industrial injury, then there are no benefits. So picking the wrong QME WILL bar you from your benefits on the denied injury.

(3) SHOULD I WAIT FOR THE QME OR APPLY FOR A HEARING? Get the QME, you must have medical evidence proving the Neck Pain is actually an Industrial INjury... just your words at a hearing are worthless, you must have a QME write the Neck Pain arose out of employment and in the course/scope of employment. AFTER you get a QME report 'proving' neck pain = industrial injury, only THEN are you ready for the Trial.

(4) MY EMPLOYER SPYING ME... the employer is permitted to investigate your claim, and your lifestyle. There is nothing you can do (except drop the claims). The employer can investigate you for both the accepted and denied claim. They can send an investigator to film you getting groceries, working in the yard, interacting with children, any moment you step out your front door.

You have no expectation of any privacy outside your front door. Even your trash at your curb is not private.

What can you do? Since you can't stop going out your front door, you need to just ignore it. BE CAREFUL not to tell a physician you cannot take out the trash when there could be photos of you taking out your trash.

I sense from your phrasing English is not your first language. I would STRONGLY suggest you hire counsel to handle both the accepted and denied claims. There are fine points in the language you may miss and get a bad outcome because of language struggles. Be sure to hire a Certified Specialist in Workers Compensation (and hire the attorney, not a clerk who brings blank forms to your place).

You have excellent Certified Specialists there in San Diego. You really should schedule a free consult with 3 or 4 until you find one that 'clicks' for you.

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Wow! That's a lot of questions that take long answers....too long to answer in this space. I suggest you schedule a free consultation with one of the many fine workers' comp attorneys in San Diego. I would recommend you not ask for a QME panel before discussing it with an attorney. That you not select a QME without discussing it with an attorney. That you not go to a QME without discussing it with an attorney. Find a good one here at or at CAAA is the association for attorneys here in California who represnt inured workers. Or you can call me for a referral.

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It often happens that additional injuries are discovered later in the claim, or that compensable consequences develop as a result of the original injury. Whether your are successful in making such a claim depends on whether the medical evidence supports a causal relationship between the accident and the additional condition or compensable consequence. You should retain an attorney right away and let them develop that evidence rather than attempting to do so yourself.

Also, you should be aware that there are time limitations for filing an original claim, as well as for adding body parts. In Virginia the limitation period is 2 years. The limitation period in your state may be shorter or longer. Even though the carrier may be paying benefits, that does not mean that your claim has been filed. FAILURE TO FILE YOUR CLAIM WITHIN THE LIMITATION PERIOD WILL RESULT IN FORFEITURE OF YOUR ENTIRE CLAIM. Therefore you should retain an attorney immediately to help you.

With respect to surveillance, there isn't much you can do to stop it. Insurers often use surveillance in court against you. They may also show it to your doctor without your knowledge, and if your doctor feels your complaints to him are inconsistent with what he sees in the surveillance tape, your wage loss benefits and medical benefits will be jeopardized.

The insurer in your case appears to be gearing up to terminate your benefits with respect to the injury they have accepted responsibility for in addition to denying your claim for injury to the additional body part. You should get a lawyer right away who practices regularly in the field of workers' compensation in the jurisdiction where your claim is pending.

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