What is an independent medical evaluation at CNESST? 

Under section 209 of the Act Respecting Industrial Accidents and Occupational Diseases (AIAOD), an employer may request that a medical expert of their choice examine an employee regarding one or more of the points 1 to 5 described in section 212 of the AIAOD.  

Section 209: An employer who has right of access to the record held by the Commission des normes, de l'équité, de la santé et de la sécurité du travail (CNESST) regarding an employment injury suffered by an employee, may require that said employee undergo an examination by a medical professional designated by the employer, each time the medical professional overseeing the employee delivers a report to the CNESST as stipulated on one or several topics referenced in subparagraphs 1 to 5 of the first paragraph of section 212. 

An employer who avails themselves of the provisions stated in the first paragraph, has the right to consult the appointed health professional for insights on how the employee’s injury or illness relates to the workplace accident they suffered or the work they perform or have performed. 

Section 212: An employer who has right of access to the record held by the CNESST concerning an employee’s workplace-related injury, has the right to challenge the designated medical professional’s certificate or report if they secure a second opinion from another medical professional who, after evaluating the employee, disputes the original findings on one or several of the following issues: 

1° The diagnosis. 

2° The projected date or timeframe for the consolidation of the injury.  

3° The nature, requirement, effectiveness or duration of the care or treatment administered or prescribed. 

4° The extent or severity of the permanent physical or mental impairment of the employee. 

5° The identification or assessment of the employee’s performance limitations. 

The employer is required to forward a copy of the report to the CNESST, within 30 days of obtaining the certificate or report they intend to dispute. 

It should be noted that the employee is obligated to attend the medical examination that has been mandated by their employer. In the event of a refusal, the employee’s income replacement benefits might be discontinued, as stated in section 142 of the AIAOD. If an independent medical assessment results in travel-related expenses for the employee, the employer must reimburse these costs and ensure the employee is paid for any time they miss from work during their scheduled hours. 

 
Process and Administration of Independent Medical Evaluation in a CNESST case 

As part of the independent medical evaluation process, the physician chosen by the employer assesses the condition of the employee who has been injured. This process follows an established protocol that differs slightly from one expert to another, based on the type of injury involved. The medical professional operates in alignment with the directives given by the employer. 

It is essential to find a medical professional that specializes in the appropriate area of medicine, as it must be aligned with the needs and type of injury presented in the case. By proceeding in this manner, they will gain a better understanding of the specifics of the case. 

Moreover, if the purpose of the evaluation is to potentially present the case in court, it is essential to ascertain whether the appointed physician is qualified to give evidence in court, since not all physicians are able to do so. 

Upon completion of the independent medical evaluation, it must be delivered to the physician overseeing the employee’s case, along with a request for a supplementary report. The latter completes the report. 

Should the views of the evaluating physician conflict with those of the attending physician, or if the attending physician fails to address the supplementary report, a procedure is initiated at the Bureau d’Évaluation Médicale (BEM). This entity is comprised of doctors appointed by the Minister of Labor, thus ensuring its independence. 

The evaluating physician for the BEM will take charge of resolving the contentious issues and has the authority to apply their judgement on points that might not be under dispute. 

The assessments of this physician often take priority in the subsequent judgements issued by the CNESST. 

The 7 scenarios requiring a health evaluation in a CNESST case  

In a case involving the CNESST, there may be several instances where an independent medical evaluation is requested. The following outlines the key scenarios that could lead to a request for an independent medical evaluation: 

1. Doubt surrounding the connection between a workplace accident or health condition and employment: If there are concerns from the employer or the CNESST regarding the correlation between a workplace incident or health condition and employment, an independent medical evaluation may be requested to determine if the employee’s health condition is indeed related to a workplace accident or occupational illness. 
2. Evaluation of work disability: In cases where the CNESST must evaluate an employee’s temporary or permanent inability to return to their work due to an accident or illness, an independent medical evaluation could be essential to determine the severity of the disability, whether it is temporary or permanent, and estimate how long the disability will last.
3. Return to work: Should a recuperating employee express a desire to return to work, an independent health evaluation may be necessary to ascertain if they are ready to take on their tasks, either fully or in a reduced manner, along with any reasonable modifications that might be needed in their work environment.
4. Disputes regarding disability rate: If the employee disputes the disability percentage established by the CNESST or their attending physician, they are entitled to request an independent medical evaluation to objectively review and evaluate the extent of their disability and the associated invalidity rate.
5. Evaluation of assistance or rehabilitation needs: In cases where an employee requires rehabilitation or support, an independent medical evaluation may be necessary to identify their specific vocational rehabilitation needs, and the adjustments required for them to resume work.
6. Inadequate medical follow-up or divergence of opinions: In situations where medical follow-up is inadequate or there are conflicting opinions, the CNESST may request an independent medical evaluation to clarify the situation and ensure an impartial assessment, particularly if the treating physician’s information is not convincing.
7. Prolonging of benefits: If an employee is currently receiving income replacement benefits and wishes to extend these payments, an independent medical evaluation could be required to establish that the work-related disability is still present and to justify the continuation of payments. 

What is an independent medical evaluation for salary insurance? 

An independent medical evaluation for salary insurance is a procedure where a non-biased physician, selected by the insurer or employer, assesses the health condition of an insured person who is currently receiving salary insurance benefits. The purpose of this evaluation is to ascertain if the person is still unable to engage in work and if they continue to satisfy the essential criteria for receiving assistance. 

Typically, an independent medical evaluation may be requested when an insurer or employer is skeptical about an employee’s inability to work, particularly if the situation last longer than initially thought or if the symptoms seem to diverge from the original diagnosis. 

The intention it to receive an unbiased medical opinion, apart from the medical files of the insured party, to enable educated decisions concerning the continuation of salary insurance benefits. 

The 6 scenarios requiring an independent medical evaluation for salary insurance benefits  

In situations involving salary insurance, it might be necessary to request an independent medical evaluation for several reasons. Here are some pertinent examples: 

1. Doubt surrounding the work disability: If an employer or insurer questions an employee’s claim of work-related disability, they have the option to seek an independent medical evaluation to determine the individual's health status. This can establish whether the disability from work is legitimate as well as identify its nature (temporary or permanent).
2. Duration of disability: In cases where the period of work disability is not clearly specified, an independent medical evaluation can provide an estimate of how long the disability may last, assisting in the management of the case.
3. Divergence of medical opinions: If there is a divergence in medical opinions, such as the patient's doctor versus the organization’s doctor, an independent medical evaluation can clarify the situation.
4. Changes in health condition: Should an individual’s health condition change; an independent medical evaluation might be requested to monitor the situation and adjust the insurance coverage as needed.
5. Request to resume employment: If the insured party is considering returning to their work, an independent medical evaluation could be requested to determine the viability of the return based on their existing health condition.
6. Dispute resolutions: If the insured individual questions the insurer’s decision (for example, if the insurer does not pay out the insurance benefit), an independent medical evaluation can be a viable solution to help resolve the matter.

 Legal procedures and scope of independent medical evaluation 

In every instance, the process of requesting an independent medical evaluation must adhere to the terms defined in the insurance contract or collective agreement, as well as conform to the prevailing legal and regulatory practices. 

Once the independent medical evaluation is completed and, in most cases, the verdict of the evaluating physician is binding, implying that insurance providers and/or employers will adhere to the conclusions exactly as they are stated by law. 

Arbitration process in case of disagreement 

In cases involving an employer’s salary insurance, if an employee disputes the findings, collective agreements typically outline an arbitration procedure, where a physician serving as an arbitrator will resolve the contested issues. This third opinion is final and binding. Consequently, the conclusions should be implemented exactly as they are stated by law. 

Getting help with your medical evaluations 

Independent medical evaluations are crucial in both CNESST and salary insurance cases. Every case comes with its own unique set of issues and requires specific expertise. 

Do you have any questions concerning independent medical evaluations? The team at Ducore Expertise is highly skilled in this area and is available to support you with your processes.  

We encourage you to get in touch with us for further details about our services.