Negotiating the Maze III: Second Independent Medical Evaluations (SIME)

If you go to a prehearing, chances are the prehearing officer will explain Second Independent Medical Evaluations (SIME). Chances are he explained a lot of things and it all sounded like a foreign language. Because it is.

Not to fret. This is what SIMEs are about:

A Second Independent Medical Evaluation is an evaluation by the Board’s doctor. Here is the list of doctors who serve on the Board: SIME doctors , bulletin 16-03.

You are entitled to a SIME when the insurance doctor (“IME”) disagrees with your treating physician. Typical disagreements are: the insurance doctor says your injuries are preexisting degeneration; your treater says they are work-related. The insurance doctor says you don’t need any treatment; your treater says you need surgery. The insurance doctor says you aren’t disabled; your treater says you can’t work because of your injury.

If you have a documented dispute between the insurance doctor and your treating physician, you should request a SIME before you go to hearing. Otherwise you can go to hearing, lay out your entire case and have the Board decide it needs an SIME before it makes a decision. Ultimately, the case will go smoother if you get ask for the SIME as soon as you have a documented dispute.

A documented dispute means that your doctor said in writing something different than the IME doctor said. That is why it’s so important for you to collect all of your medical records. Many claimants think they can rely on the medical records the insurance company files, but the truth is the doctors don’t send all of their medical records to the insurance company in order to bill them. They don’t have to. So if you rely on the insurance company’s medical records, then you might miss an important piece of evidence that is in your doctor’s file.

That is why you need to go directly to your doctors and request a complete set of records.

To see if you have a documented dispute, see if you can fill in the boxes on the SIME form wc6147: If you can quote your doctor’s chart note with the date of the entry, then you probably have the evidence of a documented dispute.

In order to get a SIME, you need to fill out a Petition rev. 2016 and attach the SIME form and the relevant medical records you are quoting.

You need to file the SIME petition with the Board, mail a copy to the insurance company’s attorney and keep a copy for yourself. A few weeks after you file the petition, the Board will schedule a prehearing conference. At the prehearing conference, the insurance company will agree or disagree with your petition.

If the insurance company agrees to the SIME, the prehearing officer will schedule deadlines.

If the insurance company disagrees, you should ask for a hearing so you can get a Board ordering the SIME. If you have documented a dispute between the IME and your treater, the Board will order the SIME.

Once the SIME is scheduled, the insurance company will arrange and pay for your travel including hotel, air and ground travel. It should mail you a check before you go to the SIME for your meals and incidentals. If it doesn’t you can amend your claim asking for reimbursement of your meals and incidentals. You will need to file copies of your receipts to show what you paid. If you missed work because of the SIME travel, you may be entitled to temporary total disability for the missed says.

The SIME doctor is supposed to mail a copy of his or her report to you and the Board 14 days after the examination. If you haven’t received the SIME report within a month, call the Board. And keep calling the Board every two weeks after that asking about the status of the SIME report.

Keenan Powell has practiced law in Alaska for more than 30 years and has dedicated her practice to Workers Compensation representing injured Alaskans.

All consultations are free.  If you want to set up a meeting, use the contact form on www.keenanpowell.com or call:  907 258 7663.

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