I have an old work comp claim from 2003. It was an accepted injury, I was rated by QME and I never settled. How in the heck can they deny my claim now citing substantial medical evidence? How do I get them to provide this "evidence" to me? Claims adjuster told me they are denying my claim because of a doctor I had surgery with in 2008 is under investigation and said they do not think now I even needed my knee surgery? Well the QME they sent me too and several other doctors wrote I needed the surgery as well and they are not under investigation.They refuse to send me the "substantial medical evidence" as to why they are denying my claim. Can I subpoena it? My QME is retired and they want to send me to another one to determine if my injury was work related. I was sent to one years ago who already determined that it was and rated me. Do I really need to do this again?
It's hard to tell without reviewing everything in the entirety. While your claim was originally accepted, it's possible the insurance company is now of the belief that the current need for treatment is unrelated to your industrial injury. This is a long shot for the insurance company but they obviously want to play hard ball. If you had a final report from a QME, why didn't you settle? If the QME has retired then they may be entitled to a new one, at least to re-evaluate the impairment. Also, the old QMEs report is probably stale and for that reason would also not amount to substantial medical evidence. Based on what you've said, their stance that the injury is non-industrial because the doctor who performed your surgery is under investigstion is nonsense. You should get an attorney ASAP.
Get an attorney to finally move the case towards a settlement. You really shouldn't handle this on your own especially taking into consideration they current nonsensical stance about compensability of your claim after such a long time.
As indicated in the two above answers, no one can prognosticate what is happening or what should happen without reviewing many documents from your claim. Is the defendant really denying your claim or just denying current medical treatment? Did the defendant obtain a court order for a new QME Panel? Do you currently have an attorney of record from whom you should be asking these questions?
And, yes, sometimes injured workers have to see a new QME, especially if the initial QME is no longer available.
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