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Medical expertise consists in asking for an expert opinion on various issues related to an individual’s health. In the workplace, it can be used in many situations, whether the employee is still working (absenteeism) or off work (e.g., disability, occupational injury, car accident).

For medical expertise to be significant and helpful in the settlement of absenteeism or disability situations, certain basic principles must be followed. To find out more about medical expertise, read the following!

Medical expertise, an invaluable tool

Medical expertise can be an invaluable tool for claims managers or human resources advisors who must make case management decisions, especially with respect to disability benefits eligibility or ability to work. By providing answers to various questions or by clarifying certain details, medical expertise provides the information needed for decision-making and for validating the attending physician’s recommendations on:

• Diagnosis
• Ability to work
• Return-to-work date, conditions of proposed return-to-work plan or back-to-work prognosis
• Treatment plan
• Functional limitations

The expert report provides an unbiased and objective opinion on a situation and the outcome of a case, as the expert has no therapeutic relationship with the person being examined, contrary to the attending physician. Along with this neutrality, the expert’s acknowledged experience, judgment and knowledge will confer strong credibility to the report, which is very useful in the event of a dispute.

However, medical expertise is, as it should be, complementary to an efficient case management process. It cannot replace the sound and disciplined management of an absenteeism problem or a disability claim.

Who can request a medical expertise?

The employer’s representative or attorney can request a medical expertise to validate a medical matter in an absenteeism or disability case.

With an insured disability plan, although the employer retains the right to request a medical expertise, it is incumbent upon the insurer to initiate and cover the cost of the expertise, when such a request is part of their case management plan. If the expertise were to be requested by the employer, for the purpose of questioning such things as the right to disability benefits or the ability to work, it could fail to be properly considered, hamper proper case management or turn out to be an unnecessary expense.

An employer who believes that a medical expertise is desirable or justified in an insured short-term or long-term disability case should discuss the matter with their insurer in order to agree on the best management strategy.

Moreover, when a dispute involving a unionized employee arises, the union or their attorney can also request a medical expertise to support the attending physician’s findings.

Finally, no matter who requested the medical expertise, the employee is always entitled to receive a full copy of the report, directly or through his/her attending physician (if the content can negatively affect the employee’s health).

Why request a medical expertise?

As already stated, medical expertise must be an integral part of the strategy used for managing absenteeism problems or disability cases, and must serve to clarify a complex situation or validate the attending physician’s recommendations.

Most of the time, a medical expertise (with a medical examination) is requested when there is doubt about an employee’s ability or inability to work. It will help understand what prevents the employee from reporting to work or performing the work expected of him/her.

Before considering the use of a medical expertise, it is important to ask the right questions in order to assess whether such medical expertise would be justified and relevant. Several aspects must be considered, including:

• Nature of the problem
• Changes in the employee’s condition and age/duration of disability case
• Points to be clarified or validated
• Information on record – Do I have all the relevant data on record to enable the expert to answer the questions?

The last point is crucial, as an expert report based on incomplete information will not be valid enough to support the decisions that will be made. If test results are yet to be received or if any relevant information is missing from the file, you must get them before preparing your mandate (the medical expertise “request”). Indeed, the rationale for requesting a medical expertise could be called into question in the light of some data that was not available at the onset. It is preferable to wait a few more weeks and make sure you have as complete a file as possible before proceeding.

On the other hand, if you are unable to get all the required information or in an emergency situation, you may ask the expert physician to collect, with the employee’s written consent, the missing information before writing his/her report. But we do not recommend this as a regular practice.

When should you ask for a medical expertise and to whom?

The timing of a medical expertise request is crucial and varies considerably from case to case. As already mentioned, all the relevant data must be collected and recorded in the file, and the expertise must fit into a sound strategy.

Also, since the employer will be legally bound by the conclusions of their expert, it is important to seek an expert with proven knowledge and experience in the specialty relevant to the situation. The expert physician’s opinion will be all the more impactful insofar as he/she has gained extensive practical experience in his/her field of expertise, pursued specialized training, written articles on the subject or been called upon as an expert in similar cases, on top of being recognized for his/her sound judgment.

Several firms offer the services of expert physicians. We recommend that you enquire about their services. But remember that ultimately, choosing the right expert is what will make all the difference.

Conclusion

Several tools are available to claims managers and human resources advisors for soundly managing absenteeism or disability cases, and medical expertise is one of them. However, while medical expertise can prove highly useful in some cases, it may be useless in other situations. It is important to be aware of this and to rely primarily on the development of the right management strategy for each situation.

If you want to request a medical expertise, start by downloading our quick reference sheet to learn how to properly draft your expertise mandate.