Expert Medical Advisers In The Resolution Of Medical Disputes
It is often the case that disputes develop with regard to the medical necessity of certain types of medical procedures. For example, if the claimant’s authorized treating physician recommends a particular procedure, the carrier, like the claimant, would have a right to an independent medical examination. If the carrier’s independent medical examination concluded that a particular surgical procedure was not medically necessary, it is likely the carrier would deny authorization for the procedure, despite the fact that it was recommended by the authorized treating physician. Alternatively, the authorized treating physician might feel the surgical procedure is not medically necessary or related to the injuries sustained in the accident. If the claimant’s independent medical examiner felt that it was medically necessary, then clearly a dispute would exist with regard to the carrier’s obligation to provide authorization for the procedure.
The workers’ compensation act contains a provision to address these types of conflicts in medical evidence: the expert medical adviser provision. The provision specifically states that in cases where there is a clear dispute regarding the need for ongoing medical treatment, or entitlement to certain categories of disability benefits, the court on its own, or through the motion of one party or the other, can be obligated to appoint an expert medical adviser. This is a physician typically selected by the Judge of Compensation Claims or, under certain circumstances, by the attorney for each party. The expert medical adviser is similar to an independent medical examiner, but the exception is that the opinion of an expert medical adviser is presumed to be correct and can be overcome only in exceptional circumstances.
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