Cal. Code Regs. Tit. 22, § 2627(c)-1 - Independent Medical Examination

(a) Scope. This section deals with the effect of a request by the director under subdivision (c) of Section 2627 of the code for independent medical examinations for the purpose of determining an individual's disability, and the effect of a request by the director under subdivision (c) of Section 2706-3 of these regulations for additional evidence by an examining physician of the continuance of an individual's disability during the period covered by a continued claim.

(b) General Principles. Independent medical examinations requested by the director shall meet all of the following conditions:

(1) The request for an examination shall be reasonable.

(2) The examining physician shall be designated by the director to obtain an independent and impartial opinion. If the claimant requests a different examining physician, the examination shall be rescheduled with another physician designated by the director.

(3) The examination and any laboratory or x-ray procedures shall be only extensive enough to determine the individual's ability to perform his or her regular or customary work and the date he or she was or will be able to do so. The examination shall not be considered to be a consultation.

(4) The fee for the examination and any laboratory or X-ray procedures shall be paid by the department in accordance with a fee schedule determined by the director.

(c) Reasonableness of Independent Medical Examination. Generally, a request for an independent medical examination is reasonable when requested in good faith in order for the department to determine its accruing and future liability for the payment of disability benefits to a claimant. Any claimant, except a resident in an alcoholic recovery home or a resident in a drug-free residential facility or an individual who depends for healing entirely upon prayer or spiritual means, as provided in Sections 2626.1, 2626.2, and 2709 of the code, may be required to submit to independent medical examinations when one or more of the following circumstances is present:

(1) Medical information received from the claimant's physician on inquiry does not conform with the guidelines established by the department's medical director regarding the normal duration of the disability, nor does the claimant's physician provide any objective medical findings that would tend to alter the expected duration of the disability.

(2) Inadequate medical information to support the existence, continuance, or an extension of a disability is received as a result of inquiry to the claimant's physician.

(3) Conflicting medical information concerning the claimant's disability is received from the same or different physicians.

(4) Documented reports of the claimant's activities conflict with reports on the claimant's disability during the same period.

(5) Additional medical evidence requested to support a continued claim for disability benefits cannot be secured without an additional fee to the claimant.

(6) Additional medical information is necessary to confirm that the claimant is, in fact, disabled.

(d) Time for Making an Appointment for an Independent Medical Examination. A claimant who receives a request to be examined in accordance with subdivision (c) of Section 2627 of the code shall contact the designated physician not later than the seventh consecutive day after the date the request was mailed by the department to the claimant to arrange for an examination on the earliest date available, except that such time shall be extended by the department upon a showing of good cause. Such request for an independent medical examination shall be cancelled if the claimant reports a recovery or return to work within the 7-day period.

(e) Failure to Submit to an Independent Medical Examination. Any claimant who fails to submit to a reasonable independent medical examination is subject to disqualification under subdivision (c) of Section 2627 of the code in the following manner:

(1) If a claimant fails to contact the designated physician within the time in subdivision (d) of these regulations, the claimant shall be disqualified from receiving disability benefits commencing with the eighth day after the date the request for an independent medical examination was mailed by the department to the claimant.

(2) If a claimant makes an appointment for an independent medical examination but fails to report for the examination, or cancels the appointment, the claimant shall be disqualified from receiving disability benefits commencing with the date of the appointment, or the date of the cancellation, whichever is earlier.

(3) If a claimant fails to comply with the request for an independent medical examination but later agrees to submit to an independent medical examination, the disqualification from receiving disability benefits shall end on the date immediately preceding the date of the examination.

(f) Results of Independent Medical Examination. Upon receipt of the report of the independent medical examiner, the department shall determine a claimant's eligibility for disability benefits in the following manner:

(1) If the independent medical examiner confirms or extends the estimated duration of disability received from the claimant's physician, the claimant shall be deemed eligible for disability benefits in accordance with the certificate furnished by the claimant's physician with respect to probable duration of the disability.

(2) If the independent medical examiner expresses an opinion that the claimant may be able to perform his or her regular or customary work at a future date earlier than the date given by the claimant's physician, the department shall request additional medical evidence from the claimant's physician to support a continued claim for disability benefits following the last day covered by the duration of disability estimated by the independent medical examiner.

(3) If in the opinion of the independent medical examiner the claimant is able to perform his or her regular or customary work on the date of the examination, the department shall review the medical information and determine the claimant's eligibility for disability benefits. If the claimant is determined able to perform his or her regular or customary work, the claimant shall be disqualified from receiving disability benefits commencing with the date of the independent medical examination.

(g) A claimant shall be notified in writing of any disqualification based on his or her failure to submit to a reasonable independent medical examination and the reasons for the disqualification. Appeals from such disqualifications may be filed in accordance with Section 2707.2 of the code and Sections 5020 through 5121 of the regulations which set forth the applicable appeals procedures.

Notes

Cal. Code Regs. Tit. 22, § 2627(c)-1

1. New section filed 8-26-93; operative 9-27-93 (Register 93, No. 35).

Note: Authority cited: Sections 305, 306 and 2602, Unemployment Insurance Code. Reference: Sections 2626, 2627 and 2706, Unemployment Insurance Code.

1. New section filed 8-26-93; operative 9-27-93 (Register 93, No. 35).