How to challenge a medical assessment?

Challenging a medical assessment is a step that can be taken by anyone who wishes to question a medical report that has consequences for their health, compensation, or return to work. Whether you have suffered a workplace accident, a traffic accident, or an occupational injury, understanding your rights and the steps to take is crucial to defending your interests and obtaining a fair and accurate report. Our health law attorneys can help you better understand all of this!

What is the role of medical assessment?

A medical assessment is an evaluation performed by a medical expert to determine the extent of an injury, functional limitations, the presence of sequelae, and the date of consolidation. It is used to assess the patient’s state of health and guide decisions made by the CNESST, the SAAQ, the employer, or an insurance company, for example. The medical report issued by the expert has a direct impact on decisions regarding compensation, return to work, or the outcome of a dispute. It often forms the basis on which agencies or courts make their decisions.

Can a medical assessment be challenged?

It is possible to challenge a medical assessment, but it is important to distinguish between the report itself and the decision that results from it. The conclusions of the medical expert can be challenged when they serve as the basis for an administrative, judicial, or civil decision. It is possible to challenge the report, the assessment of the state of health, functional limitations, or the date of consolidation. A specialized lawyer can guide you on how to challenge and maximize your chances of success.

What are the reasons for challenging a medical assessment?

There are several grounds for challenging an assessment:

• Disagreement with the conclusions: if the medical expert’s conclusions do not accurately reflect your state of health or functional limitations.
• Error in the assessment: if the clinical examination or expert report contains omissions or inaccuracies.
• Conflict of interest: if the medical expert has a connection with the employer or insurance company that could compromise their objectivity.
• New medical information: if recent documents or examinations change the initial assessment.

How to challenge a medical assessment depending on the organization concerned?

The procedure depends on the context of the assessment.

Challenging a medical assessment related to the CNESST

For a work accident or occupational injury:

1. Request an administrative review from the CNESST.
2. File an appeal with the Tribunal Administratif du Travail (TAT) if the review does not change the decision, within 60 days from the date of the decision.

Challenging a medical assessment related to the SAAQ

For a traffic accident:

1. Contact the SAAQ to request a reassessment.
2. Obtain a second opinion from an independent medical expert to strengthen your case.
3. File an appeal with the Tribunal Administratif du Québec (TAQ) if necessary.

Challenge a medical assessment related to an employer or insurance company.

1. Consult your treating physician for an independent evaluation.
2. Request a second opinion.
3. Challenge the employer’s or insurer’s decision if it is deemed incorrect.

Situations outside the CNESST, SAAQ, or employer

If you are contesting a medical assessment in a private, civil, or insurance context:

1. Obtain a second opinion from an independent medical expert to verify the conclusions.
2. Submit all relevant documents: medical records, clinical examinations, imaging, or tests.
3. Contact the organization or insurance company in writing to request a review.
4. Hire a specialized lawyer to organize the challenge, obtain an expert report, and represent you in the event of a legal dispute.

These steps allow you to challenge the medical expert’s conclusions, assess your health objectively, and assert your rights in any type of appeal or claim for compensation.

What are the deadlines for contesting a medical assessment?

Compliance with deadlines is crucial to the validity of the contestation.

• CNESST: a request for review of a decision must be submitted within 30 days of receipt. If the decision is upheld, an appeal may then be filed with the Administrative Labor Tribunal within 60 days.
• SAAQ: When a medical assessment is involved, it is recommended that you act quickly to protect your rights and check the legal deadlines applicable to your situation.
• Employer or private insurance: act quickly after receiving the medical report, in accordance with collective agreements or insurance policies.

Keep all documents relating to your health and medical records. The date of consolidation and the date of the clinical examination are essential for calculating deadlines.

How to properly prepare a medical expert opinion challenge?

1. Gather and consolidate your medical records

Before taking any action, it is crucial to consolidate all documents: previous medical reports, notes from your treating physician, clinical examinations, imaging results, and specialized assessments. The more complete your file is, the better the expert will be able to assess your health and identify discrepancies with the contested report.

2. Choose an independent expert for a second opinion

The choice of an independent medical expert is crucial. They must be recognized in their medical field and able to answer the following questions:

• confirm or qualify the initial diagnosis;
• assess the sequelae and functional limitations;
• analyze the methodology of the initial report;
• issue a solid expert report that can be used in an appeal against the contested decision or conclusion.

A good expert does not simply repeat the initial report, but compares the conclusions and provides an opinion based on clinical and objective evidence.

3. Formulate the appeal

The appeal can be made to the organization that requested the assessment or directly to the insurance company or employer, depending on the context. The process generally includes:

• submitting a letter of appeal;
• including the second opinion and medical records;
• formulating specific arguments to challenge the conclusions or decision rendered.

If the organization refuses to review its decision, it is possible to bring the dispute before a competent court, particularly for civil liability, traffic accident, or workplace accident disputes.

Tips for effectively challenging a medical report

1. Identify gaps and contradictions

To challenge a report, you need to highlight any inconsistencies:

• omission of essential clinical examinations;
• contradictions with the medical file or the opinion of a treating physician;
• conclusions based on unverified assumptions.

2. Present a second opinion

A second opinion can demonstrate that the initial report did not accurately assess the individual’s health or functional limitations. The independent expert can also clarify the actual impact on the individual’s return to work or entitlement to compensation.

3. Argue about consolidation and sequelae

In some cases, the medical expert may have set a consolidation date too early or minimized the extent of the occupational injury. Challenging these points can influence the duration of care, the amount of compensation, or the recognition of a relapse.

What are the possible scenarios following an appeal?

After appealing a medical assessment:

• The organization or insurance company may review the decision.
• The initial decision may be upheld despite the appeal.
• New rights may be recognized, such as additional compensation or recognition of sequelae.
• Legal action may be considered to assert your rights.

Seek assistance from a specialized lawyer

Hiring a specialized lawyer can change the whole process. The lawyer identifies the deadlines for challenging the decision, advises on the choice of a medical expert and the drafting of the mandate, analyzes the initial report, and challenges the conclusions in a structured manner. They then help consolidate the file, including all relevant documents, and prepare the brief or challenge. Finally, they can represent the client before administrative or judicial bodies to maximize the chances of winning the case.

A specialized lawyer will know how to ask the right questions, verify that the clinical examination was conducted rigorously, and ensure that the conclusions accurately reflect the actual state of health. The assistance of an experienced medical liability lawyer, a personal injury lawyer, or more generally a health law lawyer, is therefore essential.

Frequently asked questions

Can a medical report by an expert physician be challenged directly?

Yes, more specifically, the decision or conclusions of the report can be challenged. A second opinion allows for a contradictory opinion to be provided.

What are the deadlines for challenging a CNESST decision?

You have 60 days after receiving the decision to file an appeal with the TAT.

Do you need a specialist doctor for the second opinion?

Yes, they must be an expert in their field to correctly assess your state of health and functional limitations.

What role does the lawyer play?

The lawyer structures the challenge, selects the right expert, and represents the client before the competent authorities.

What if the challenge is unsuccessful?

You can consider legal action to assert your rights.

Can all accidents or illnesses give rise to a challenge?

Yes. Whether it is a traffic accident, a workplace accident, or any medical condition assessed by a medical expert, it is possible to challenge the conclusions and issue a second opinion.

Is it worthwhile to challenge?

The challenge must be proportionate to the potential gain and the impact on your compensation or your rights.