OBJECTION TO INDEPENDENT MEDICAL EXAMINATION (IME)

(Workers' Compensation Medical Evaluation Dispute)

PART 1: CASE INFORMATION

DATE OF OBJECTION: [DATE]

CLAIM NUMBER: [NUMBER]

WCAB/BOARD CASE NUMBER: [NUMBER]

DATE OF INJURY: [DATE]

PART 2: PARTIES

2.1 Injured Worker (Objecting Party)

Name: [FULL NAME]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE NUMBER]

Email: [EMAIL]

2.2 Injured Worker's Attorney

Name: [ATTORNEY NAME]

Firm: [FIRM NAME]

Bar Number: [NUMBER]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE]

Fax: [FAX]

Email: [EMAIL]

2.3 Insurance Carrier/Employer

Carrier/Employer Name: [NAME]

Claims Examiner: [NAME]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE]

2.4 Defense Attorney

Name: [NAME]

Firm: [FIRM]

Address: [ADDRESS]

Phone: [PHONE]

PART 3: IME NOTICE INFORMATION

3.1 IME Appointment Details

Date of IME Notice: [DATE]

Scheduled IME Date: [DATE]

Scheduled IME Time: [TIME]

Scheduled IME Location:
[ADDRESS]
[CITY], [STATE] [ZIP CODE]

Distance from Injured Worker's Residence: [MILES]

3.2 Designated Examiner

IME Physician Name: [NAME], [CREDENTIALS]

Specialty: [SPECIALTY]

Medical License Number: [NUMBER]

Practice/Facility Name: [NAME]

Address: [ADDRESS]

Phone: [PHONE]

PART 4: GROUNDS FOR OBJECTION

4.1 Objection Categories

Injured Worker objects to the scheduled IME on the following grounds:

☐ IMPROPER NOTICE
- Notice was not timely (less than [STATE REQUIREMENT] days)
- Notice was incomplete or deficient
- Notice sent to wrong address

Details:
____________________________________________________________________________

☐ EXAMINER BIAS OR CONFLICT OF INTEREST
- Examiner has previously evaluated this claimant adversely
- Examiner is known for consistently defense-favorable opinions
- Examiner has financial relationship with carrier
- Examiner's practice primarily consists of IME work for insurance carriers

Details:
____________________________________________________________________________

☐ INAPPROPRIATE SPECIALTY
- Examiner's specialty does not match the body parts/conditions at issue
- Claimed body parts: [LIST]
- Examiner's specialty: [SPECIALTY]
- Appropriate specialty would be: [SPECIALTY]

Details:
____________________________________________________________________________

☐ EXCESSIVE DISTANCE
- IME location is unreasonably far from injured worker's residence
- Distance: [MILES]
- Reasonable distance in this state: [MILES]
- Transportation difficulties: [EXPLAIN]

Details:
____________________________________________________________________________

☐ SCHEDULING CONFLICT
- Injured worker has work obligations: [EXPLAIN]
- Injured worker has medical appointments: [DATE/PROVIDER]
- Injured worker has childcare/family obligations: [EXPLAIN]
- Other unavoidable conflict: [EXPLAIN]

Alternative dates proposed:
1. [DATE AND TIME]
2. [DATE AND TIME]
3. [DATE AND TIME]

☐ DUPLICATIVE OR UNNECESSARY EXAMINATION
- Recent QME/AME evaluation was performed: [DATE]
- Recent PTP evaluation addresses same issues: [DATE]
- No new medical issue justifies additional examination

Details:
____________________________________________________________________________

☐ SCOPE OF EXAMINATION
- Requested examination exceeds scope of legitimate inquiry
- Examination includes body parts not claimed
- Examination includes inappropriate procedures

Objectionable scope:
____________________________________________________________________________

☐ PROCEDURAL DEFECTS
- IME was not properly requested under state procedures
- Required state process was not followed (e.g., QME process bypassed)
- Other procedural violation: [EXPLAIN]

Details:
____________________________________________________________________________

☐ MEDICAL CONDITION PRECLUDES ATTENDANCE
- Injured worker's current condition prevents travel
- Injured worker's condition prevents lengthy examination
- Supporting documentation: [ATTACH]

Details:
____________________________________________________________________________

☐ OTHER GROUNDS

____________________________________________________________________________

____________________________________________________________________________

PART 5: DETAILED OBJECTION STATEMENT

5.1 Statement of Facts

[PROVIDE DETAILED FACTUAL BACKGROUND SUPPORTING THE OBJECTION]

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

5.2 Legal Argument

[CITE APPLICABLE STATUTES, REGULATIONS, AND CASE LAW SUPPORTING THE OBJECTION]

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

PART 6: EXAMINER-SPECIFIC OBJECTIONS

6.1 Objections to Designated Examiner

Examiner: [NAME]

Reasons for Objection to This Examiner:

☐ Prior adverse evaluation of this injured worker
Date of prior evaluation: [DATE]
Findings: [SUMMARY]

☐ Known defense bias
Evidence:
____________________________________________________________________________

☐ Lack of appropriate credentials
Required credentials: [SPECIFY]
Examiner lacks: [SPECIFY]

☐ Disciplinary history
[DESCRIBE ANY KNOWN DISCIPLINARY ACTIONS]

☐ Other:
____________________________________________________________________________

6.2 Alternative Examiner Request

If the IME must proceed, injured worker requests:

☐ A different examiner in the same specialty
Suggested examiner(s): [NAME(S)]

☐ An examiner closer to injured worker's residence

☐ An examiner selected through proper state procedures (QME panel, etc.)

☐ Other accommodation: [SPECIFY]

PART 7: REQUESTED RELIEF

7.1 Relief Sought

Injured Worker requests that:

☐ The scheduled IME be cancelled

☐ The IME be rescheduled to: [PROPOSED DATE(S)]

☐ The IME location be changed to within [MILES] of injured worker's residence

☐ A different examiner be designated

☐ The IME be conducted through proper state procedures (QME process)

☐ The scope of the IME be limited to: [SPECIFY]

☐ The injured worker be permitted to have a witness/representative present

☐ The examination be video or audio recorded

☐ Other relief: [SPECIFY]

7.2 Conditions for Attendance

If the IME proceeds, injured worker requests:

☐ Advance provision of all medical records to be reviewed by the examiner

☐ Written confirmation of examination scope and procedures

☐ Reasonable examination duration (not to exceed [TIME])

☐ Rest breaks as needed

☐ Interpreter services (Language: [LANGUAGE])

☐ Transportation assistance

☐ Other: [SPECIFY]

PART 8: STATE-SPECIFIC PROCEDURES

8.1 California

☐ This objection asserts that:
- The carrier is attempting to bypass the QME process
- Represented applicant is entitled to QME/AME evaluation, not carrier-selected IME
- Request for QME panel should be filed instead

☐ For unrepresented applicants:
- Carrier may schedule a single examination with a QME
- Objection to specific QME on panel

8.2 [YOUR STATE]

[INSERT STATE-SPECIFIC IME PROCEDURES AND OBJECTION RIGHTS]

____________________________________________________________________________

____________________________________________________________________________

PART 9: CONSEQUENCES OF NON-COMPLIANCE

9.1 Notice to Insurance Carrier

PLEASE TAKE NOTICE:

If this objection is overruled or the IME is deemed proper, the injured worker:

☐ Will attend the rescheduled IME at a mutually agreeable time

☐ Reserves all rights to challenge the IME findings

☐ May request a deposition of the IME physician

☐ May present contrary medical evidence

9.2 Notice to Injured Worker

Important: Failure to attend a properly scheduled IME may result in:
- Suspension of benefits
- Adverse inference in proceedings
- Other penalties under state law

PART 10: CERTIFICATION

I, [NAME], declare under penalty of perjury that:

☐ The statements in this objection are true and correct to the best of my knowledge.

☐ This objection is made in good faith based on legitimate concerns.

☐ I have served a copy of this objection on all parties as indicated below.

Signature: _________________________________

Printed Name: [NAME]

Title: [ATTORNEY/INJURED WORKER]

Date: [DATE]

PART 11: PROOF OF SERVICE

I declare that on [DATE], I served a true copy of this Objection to IME on:

Method of Service:
☐ Fax - Fax Number: [NUMBER], Date/Time: [DATE/TIME]
☐ Email - Email Address: [EMAIL], Date/Time: [DATE/TIME]
☐ First Class Mail - Date Mailed: [DATE]
☐ Personal Service - Date/Time: [DATE/TIME]

Signature: _________________________________

Printed Name: [NAME]

Date: [DATE]

PART 12: RESPONSE DEADLINE

Response to this objection is requested by: [DATE - typically 5-10 days]

If no response is received, injured worker will:
☐ File a motion/petition with the Workers' Compensation Board
☐ Not attend the scheduled IME pending resolution
☐ Other: [SPECIFY]

PART 13: ATTACHMENTS

☐ Copy of IME notice
☐ Map showing distance from residence to IME location
☐ Documentation of scheduling conflict
☐ Medical documentation supporting inability to attend
☐ Evidence of examiner bias
☐ Prior evaluation reports from this examiner
☐ State regulations regarding IME requirements
☐ Other: [SPECIFY]

[END OF DOCUMENT]