The Role Of Medical Evidence In Workers’ Compensation Cases

No one wants to go to the doctor, especially not frequent medical appointments. The poking and prodding, testing, and treatments can be wearing after a while. If you’ve been injured at work, you probably know the routine well. You might feel like you are getting pulled in all directions with the insurance company, your employer, your doctors, and your attorney all vying for your attention and compliance.

Our advice: get an experienced worker’s comp attorney and let them take care of the insurance company and anyone else for you.

In a worker’s compensation case, the medical evidence that is presented can be the difference between winning a lucrative settlement and getting a very low one. While it may not be convenient to go to frequent doctor’s appointments, see various specialists, and get regular treatments, it is necessary to establish a history and ensure that your injuries are well documented.

So, before you complain about all of the appointments that you have to go to, review this guide to get a better understanding of the role medical evidence plays in your worker’s compensation case and why it is so important to you.

What is the importance of medical records in a worker’s compensation claim?

Insurance companies won’t make a move to accept a worker’s compensation claim (or deny it) without first reviewing all the evidence that is available in the case. A big part of that evidence is the medical record that has been built since the injury occurred.

The insurance company will look at the report that the claimant filled out at work when they reported the injury. They will compare this report to the medical records of the claimant’s appointments and treatments. If there are discrepancies between them, the insurance company can deny the claim.

The insurance company is also looking for evidence that they can use against the claimant so that they can deny the claim. They are looking for old injuries or pre-existing health issues that may have been discussed in the appointments as well as drug tests that may show illegal drugs or alcohol in the claimant’s blood work.

Medical records are also a valuable tool to use to guide treatment. They can be used to determine if a particular treatment or procedure is medically necessary which means that worker’s compensation insurance would cover it.

The claimant’s medical history can also provide clues to the overall health of the individual. Earlier injuries or pre-existing health conditions  could disqualify them from worker’s compensation unless the injury made the situation worse than it was before. In the United States, a previous injury or pre-existing condition can cause a worker’s compensation claim to be denied unless the injury worsens the condition or illness and it was not caused by their presence.

For example, if the claimant had arthritis in his or her back and had a back injury on the job, the insurance company could deny their claim or reduce their benefits. They can do this because the work-related injury is exacerbated or worsened by the pre-existing condition. It could also impact the treatment costs that the insurer is willing to cover or is required to cover because the pre-existing condition could affect the claimant’s recovery.

While it may seem like a good idea to withhold information on an earlier injury or pre-existing condition, it really isn’t. If during the claims review the insurance company discovers that the claimant was not forthcoming with disclosing their history of arthritis in the spine, the physician may determine that the claimant is not trustworthy. The insurance company can also automatically deny the claim, and the physician for the claimant could even withdraw their support for the case.

How do lawyers get your medical records?

Lawyers can obtain their clients’ medical records by filing a formal request. They can have the claimant sign a release form authorizing the attorney to receive their medical records. It is very important for the worker’s compensation attorney to have that information.

Insufficient documented medical evidence is one of the most common reasons that worker’s compensation claims are delayed or denied.

The attorney will submit the request for records to every doctor that their client sees, as well as any treatment facilities which can include physical therapy, chiropractic care, and others.

Why is it important to maintain separate medical and billing records in worker’s compensation cases?

It is very important that all medical information related to a work injury or illness is separate from regular doctor’s appointments. However, if the claimant has other appointments with the same doctor for unrelated issues, it is easy for the two to get mixed up.

Keeping the records and bills from the injury separate makes them much easier to work with.  It is also necessary because the bill is going to the worker’s comp insurance company. It is not wise for the claimant to separate the documentation on their own, nor is it a good idea to risk medical records unrelated to the work injury ending up in the hands of the insurance company.

What are the types of medical evidence?

There are several types of medical evidence that the insurance company and the attorney may use in a worker’s compensation case.

  • Independent Medical Examination (IME) – This can vary depending on the worker’s comp insurance provider and the company.  It is important to note that the IME physician is actually working for the insurance company and is not really the victim’s doctor. This is typically not good for the doctor/patient relationship. The report that the IME generates is also often problematic. It could be comprehensive or it could be just a snapshot.
    • Comprehensive reports – This is a better report because it is specific and gives explanations. However, the doctor is still working for the insurance company and not the victim so the results could be a bit skewed.
    • Snapshot reports – Snapshot reports are a brief summary that is completed after the medical exam. It is heavily based on the physical exam, leaving the information very general, broad, and the conclusions non-specific.
  • Supplemental medical evidence – This type of medical evidence can be anything that supports or provides additional information on the claimant. It could come from a second opinion, an examination by an expert or specialist, or an expert’s review of the medical evidence that has already been generated.

If you have been injured at work, you need an attorney who will fight for you and get you the compensation that you deserve. You need the worker’s compensation attorneys at the Law Office of Mary E. Jordan. Call today for your free case evaluation. We’ll discuss your case with you and outline some next steps which may include getting you in to see doctors who can actually help you and who will provide the medical evidence necessary to get you approved and validate your claim.

Don’t wait to see what happens or try to handle your claim alone. Cash in on the experience, skill, and commitment that our entire legal team offers, and get what you deserve.

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