THE INSURERE REFUSES TO GIVE ME A RATING

If you receive a Notice of Intention to Close Claim, call your adjuster and ask whether the adjuster intends to schedule you for a rating evaluation. Usually, the adjuster does not intend to schedule a rating if that claim closure notice is sent. Instead, the adjuster would have sent a letter scheduling you for a rating evaluation. Once you confirm that the insurer has no intention of scheduling a rating evaluation, you must file an appeal on the form provided with the Notice of Intention to Close Claim, and then follow the same steps you would if you disagreed with a rating evaluation and wanted a second rating under NRS616C.100.

 

The insurer is not required to schedule every claim for a rating evaluation. The adjuster must schedule a rating evaluation only when the treating doctor states in his dictated report, or in the final progress report, that it appears likely that the injured worker has a ratable impairment. The problem is that many surgeons who are authorized to treat injured workers are not familiar with the criteria for ratable impairments. These surgeons sometimes mistakenly write that there is no ratable impairment if the patient is able to return to his job full duty. When there is a question about the likelihood of a ratable impairment, the adjuster should send the treating doctor that portion of the AMA Guide to Evaluation of Permanent Impairment that is relevant to the injury when asking the doctor to clarify whether there is a likely impairment. Adjusters rarely do that though. Instead, the attorney for the injured worker must try to obtain a reply from the doctor to a letter sent by the attorney that shows the doctor that the Guide allows for a rating for the injury.

 

Again, the steps for obtaining a rating where the insurer refuses to schedule an impairment evaluation are the same steps taken by injured workers who want a second rating evaluation. The injured worker sends a request for assignment of a rating physician to the DIR, and indicates on the form that the insurer never scheduled a first rating. The injured worker must send the assigned rating doctor a complete copy of her medical records before the scheduled evaluation, and must pay the established rate for the evaluation. If the rating doctor finds an impairment, the report is given to the hearings officer, who may order the insurer to pay the percentage of impairment found by the rating doctor, and may order the insurer to reimburse the injured worker for the cost of the rating.

 

If you cannot afford to get a rating evaluation prior to your appeal hearing, you may be able to convince the hearings officer to order the insurer to schedule a rating. You must be able to show that the medical records alone show that you have a ratable impairment under the criteria of the AMA Guides. For example, you could show the hearings officer the page from the AMA Guide where it states that a 1% whole person impairment is given for a partial meniscectomy, and also show the hearings officer your operative report for your partial meniscectomy. However, you must be very knowledgeable about the criteria in the AMA Guides if you hope to convince a hearings officer that you do have a likely impairment when the treating physician reports that you don't.

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