|
< Date >
< Doctor's Name >
< Doctor's Address >
Dear Dr. < Surname >,
| Re: |
Request for an Opinion
on the NEL Medical Assessment
< Your Name > |
| WSIB Claim No.: |
< Your Claim Number
> |
I have concerns about the Workplace Safety
and Insurance Board's (WSIB) assessment of permanent impairment resulting
from my workplace injury. WSIB provides a Non-Economic Loss (NEL)
award for permanent impairment based on an independent medical assessment.
I have enclosed a copy of the assessment report with this letter.
You are being asked to examine the medical
condition(s) noted on page one of the assessment and to compare
your results with those in the report. If you find the assessment
does not contain any significant errors or, if in your opinion,
I have not suffered a significant deterioration since that assessment,
please inform me that the assessment is accurate. No report is
required or necessary.
If you agree that there are major problems
with the assessment or if you feel that I have had a significant
deterioration, please prepare a report for WSIB. Your report should
include the following:
- Give my name and claim number, the date
of your examination, and a statement noting you have read the
NEL medical assessment.
- Your report need only concentrate on
those points where your findings differ significantly from those
in the NEL assessment. In particular:
- Did the assessor miss some important
part of the impairment?
- Did the assessor underestimate some
portion of the impairment?
- Did the assessor incorrectly estimate
the likely future consequences of the impairment (is the assessor
guessing)?
- Was some part of the assessment conducted
in a manner contrary to the techniques provided in the AMA
Guides?
- Particularly important in your report are
the differences in measurable objective physical or psychological
findings, diagnosis, and prognosis (with emphasis on how my condition
has become significantly worse compared to the NEL medical examination
if this is for a re-assessment).
- You need not comment on the percentage of
the NEL award unless you have some expertise in conducting assessments
under the AMA Guides. In that case, please state the nature of
your expertise.
I will send the report to the appropriate person
at WSIB.
If you intend to charge a fee for our
report to WSIB, please discuss this with me prior to preparing the
report. You may bill WSIB. WSIB has a fee schedule and may reimburse
you. WSIB pays for helpful medical reports that assist in the decision-making
process.
I thank you in advance for your assistance
and attention to this and look forward to receiving your report.
Yours truly,
< Sign Your Name Here >
< Type/Print Your Name >
< 123 Your Street >
< Your City, Ontario >
< X0X 0X0 >
Enclosure
|
