Here’s what happens after a QME in California: the evaluator has 30 days from your exam to send a medical-legal report to you, the claims administrator, and your attorney, and that report becomes the central piece of evidence driving your permanent disability rating, your future medical care, and the final value of your workers’ compensation claim. From the day it lands, you’re on a clock to review it, correct errors, and decide whether to challenge the findings before the claim moves to settlement or hearing.
The 30-Day Report Deadline
California regulations give the QME no more than 30 days after the examination to prepare and submit the initial comprehensive medical-legal report. The evaluator can request an extension from the DWC Medical Director, but absent that, 30 days is the deadline.
Once completed, the report goes to you, the claims administrator, and your attorney if you have one. Represented workers usually see the report through their lawyer first. Unrepresented workers receive it directly, along with required notices about their rights. When the report addresses permanent disability, the QME must also complete and serve a Permanent and Stationary Status and Work Capacity form (DWC-AD Form 10133.36) alongside the report.
What the Report Decides
This is not a second opinion from your treating doctor. It is an independent evaluation designed to resolve the disputed medical issues in your claim, and the evaluator must address every contested medical issue within their scope of practice that arose from your reported injuries before the appointment date.
A complete report typically covers:
- Causation: whether your injury or illness is work-related
- Diagnosis: the specific medical conditions resulting from the industrial injury
- Permanent and stationary status: whether your condition has stabilized or still needs active treatment
- Permanent impairment: a rating of lasting physical or functional limitations under the AMA Guides to the Evaluation of Permanent Impairment (5th Edition)
- Apportionment: what percentage of your permanent disability was caused by the work injury versus other factors
- Future medical care: recommendations for ongoing treatment
- Work restrictions: physical limitations affecting your return to work
The impairment and apportionment sections deserve the closest reading, because they translate directly into money.
How the Report Becomes a Dollar Figure
The QME’s impairment number is only the starting point. Under California Labor Code section 4660, the raw whole-person impairment percentage from the AMA Guides gets adjusted through the Permanent Disability Rating Schedule based on your occupation, age at the time of injury, and diminished future earning capacity. The result is a permanent disability percentage between 0% and 100% that controls your weekly benefit rate and the number of weeks you’ll be paid. The DWC’s Disability Evaluation Unit can issue a formal rating from the QME’s findings, or the parties can calculate it themselves using the schedule.
The difference between a 25% and a 35% rating can represent thousands of dollars, so how the QME describes your impairment matters.
Apportionment and Pre-Existing Conditions
Apportionment is where many injured workers lose money without realizing it. Under California Labor Code section 4663, apportionment of permanent disability must be based on causation. The QME is required to estimate what approximate percentage of your permanent disability was caused by the work injury and what percentage was caused by other factors, including prior injuries, aging, or pre-existing conditions.
Your employer is only liable for the percentage directly caused by the work injury. If a QME finds that 60% of your back disability came from the industrial injury and 40% from a degenerative condition that predated it, your permanent disability benefits are reduced by 40%. On a significant claim, that reduction can reach tens of thousands of dollars.
If you have prior workers’ compensation awards for permanent disability, California law creates a conclusive presumption that the prior disability still exists at the time of any new injury. Accumulated permanent disability awards for any single body region cannot exceed 100% over your lifetime. The statute breaks the body into specific regions: hearing, vision, mental and behavioral disorders, the spine, upper extremities (including shoulders), lower extremities (including hips), and a catch-all category covering the head, face, cardiovascular system, respiratory system, and everything else.
A vague or poorly supported apportionment finding is challengeable. If the report says “50% apportioned to pre-existing degeneration” without explaining the medical basis, that’s a weakness to raise through a supplemental report or deposition.
Reviewing and Challenging the Report
Read the report carefully, even if you have an attorney. You know your medical history, your symptoms, and the details of your injury better than anyone. Look for factual errors: wrong dates, incorrect descriptions of how the injury happened, medical conditions attributed to you that you don’t have, or symptoms you reported that the evaluator left out. These mistakes can quietly drag down your rating or shift causation away from the work injury.
Factual Corrections
For straightforward factual errors, you can request a factual correction under Title 8, California Code of Regulations, section 37. This is the fastest route for fixing things like incorrect dates of injury, wrong job descriptions, or medical history errors. It is a narrower process than a supplemental report request.
Supplemental Reports
For more substantive disagreements, such as a causation determination you believe is wrong, an apportionment finding that ignores key evidence, or work restrictions that don’t reflect your actual limitations, you can request a supplemental report. The request must be in writing and should include any new medical records that weren’t available during the original evaluation. Once the QME receives the request, regulations give the evaluator up to 60 days to complete the supplemental report, with a possible 30-day extension if both parties agree.
Deposing the QME
Either party can depose the QME to challenge or clarify the findings under oath. A deposition lets your attorney question the evaluator about the reasoning behind specific conclusions, test whether the apportionment holds up, and create a record the Workers’ Compensation Appeals Board can weigh. The QME must make themselves available, typically at or near the location of the evaluation. Depositions add cost but can be decisive when the report’s conclusions are poorly reasoned or contradicted by other medical evidence.
Replacing the QME
Replacement is possible only under specific regulatory grounds: the QME practicing in the wrong specialty, inability to schedule within 90 days, a prior treating relationship for the same injury, or a documented medical reason that makes the assigned evaluator inappropriate. You cannot replace a QME simply because you disagree with the report’s conclusions.
How the Claim Resolves
Once the report is finalized and any challenges are resolved, the claim moves toward resolution. The report’s findings frame the negotiation: your permanent disability percentage sets the benefit floor, the future medical care recommendations define ongoing treatment costs, and the work restrictions shape any vocational rehabilitation discussion.
Stipulated Award
A stipulated award is an agreement between you and the claims administrator on the permanent disability rating and the need for future medical care. Disability benefits are paid out over time at a weekly rate determined by your rating percentage. Importantly, a stipulated award keeps your right to future medical care open. If your condition worsens or you need additional treatment related to the injury later, you can seek it. For injuries that may require ongoing care, this matters a lot.
Compromise and Release
A compromise and release is a lump-sum payment that closes the entire claim, including future medical care, in exchange for a single negotiated amount. Once you sign, you generally cannot reopen the claim for additional treatment. The lump sum is typically calculated by combining the present value of your remaining permanent disability payments with an estimate of future medical costs, then adjusting for the risk and delay of continued litigation. A C&R makes sense when the parties disagree significantly on the claim’s value and want certainty, or when you prefer a lump sum to years of weekly payments.
When Negotiations Fail
If you and the claims administrator cannot reach an agreement, the Workers’ Compensation Appeals Board steps in. A workers’ compensation administrative law judge can hold a hearing, weigh the QME report against the other evidence, and issue a findings and award.
Supplemental Job Displacement Benefits
If the report finds you have a permanent partial disability and your employer does not offer you modified or alternative work, you may qualify for a Supplemental Job Displacement Benefit. The SJDB is a non-transferable voucher you can use to pay for educational retraining or skill enhancement at accredited schools. The claims administrator is responsible for issuing the voucher if you qualify. The benefit is for workers whose injuries prevent them from returning to their previous job and whose employers have no suitable position available.
Tax Treatment of What You Receive
Workers’ compensation benefits paid under California law are fully exempt from federal income tax. This applies to weekly temporary disability payments, permanent disability payments, lump-sum settlements, and medical expense reimbursements. The form of payment does not matter: whether you receive weekly checks through a stipulated award or a single lump sum through a compromise and release, the workers’ compensation portion is not taxable income.
One wrinkle involves Social Security Disability Insurance. If you receive both workers’ compensation and SSDI, federal law caps the combined total at 80% of your average current earnings before the disability. When the combined amount exceeds that threshold, the Social Security Administration reduces your SSDI benefit by the excess. The workers’ compensation payment itself stays tax-free, but the SSDI portion may be taxable depending on your total income. This offset continues until you reach full retirement age or your workers’ compensation benefits stop, whichever comes first.
If you return to work and receive salary for light-duty assignments, that income is taxable as regular wages even though your underlying workers’ compensation benefits remain exempt.