Medical Records and Your Workers’ Compensation Case
Insufficient medical documentation is, by far, the most common reason that workers’ compensation claims are denied or delayed. This is true at all stages of a workers’ comp. case.
Steve Zoni 508-822-2000
Information Contained within Your Medical Records Affect Whether Your Claim will be Paid or Denied at all Stages of your Case
After an injury is first reported to the workers’ comp. insurance company, an insurance adjuster must decide whether to pay or deny the claim within fourteen days. This decision based mostly on the language contained in early medical records written by the injured worker’s doctor and provided to the insurance company either by the injured worker, the doctor, the workers’ attorney, or by the employer.
If the insurance company denies the claim at first, it may later decide to accept the claim as more medical records become available, so long as the additional records contain the necessary language.
If a workers’ claim is denied and the worker needs to bring a formal case against the insurance company, which is best done with the help of an attorney, there will be one or more court dates. At any court date, if new records are available that contain sufficient information, the insurer may decide to accept the claim.
Sometimes, the case will need to be heard by a judge, who may order an unwilling insurance company to accept a claim and pay for medical treatment and lost wages. Judges make this decision based in large part on the contents of medical records.
Thus, at all stages of a workers’ compensation case, the contents of the medical records are very important.
What is Medical Documentation?
The medical documentation needed to support a workers’ compensation claim is usually a written or type note, prepared and signed by your doctor. This could be a hand written note on a prescription pad or on the doctor’s letterhead. It could also be the doctor’s handwritten notes contained within the workers’ chart, the file kept by the doctor’s office. Commonly, workers’ compensation cases are documented by the doctor’s treatment notes; these are the final, signed, usually typed record that the doctor prepares after examining a patient.
The format of the documentation is not usually important, so long as it is signed by a doctor, physician’s assistant, nurse, or other qualified medical provider. The important part is the contents of the documentation.
To Receive Workers’ Compensation, the Medical Records Must Support Your Case, whether it is for Medical Treatment, Wage Benefits, or Both
Workers’ compensation benefits usually involve two parts: medical treatment and weekly wage benefits.
If an insurance company or a judge is considering whether to pay for an injured workers’ medical treatment, the insurer or judge will be looking for language that states two things. First, the documentation must state the type of treatment that the doctor is recommending. Second, and most important, the documentation must state that the worker requires the treatment to address a medical issue that was caused by work; either a specific injury or the worker’s repetitive job duties.
If an insurance company or a judge is considering whether to pay for an injured workers’ lost wages, the insurer or judge will again be looking for language that states two things. First, the documentation must state that the worker has a work disability; this means that the worker has certain medical restrictions that prevents the injured worker from earning full wages, sometimes the doctor will provide certain physical restrictions such as “no lifting,” sometimes the doctor may simply say “light duty only” or “no work at this time.” Second, and most important, the documentation must again state that the worker’s disability is due to a medical issue caused by work; either a specific work injury or the worker’s repetitive job duties.
Sometimes, injured workers have pre-existing conditions or other medical issues that may be partially to blame for the worker’s disability or need for medical treatment. In this circumstance, when the doctor comments on the cause of the injury, the insurance company or a judge will be looking for language that states that the specific work injury or repetitive job duties is “a major cause” or “a significant factor” in bringing about the disability or need for treatment. The law does not require that the work injury be the only cause of a disability or need for treatment in order to receive workers’ compensation benefits.
Sometimes the doctor may not be one hundred percent certain as to what caused an injury. When a doctor is uncertain, injured workers are still entitled to workers’ compensation benefits as long as the doctor explains that the work injury or repetitive job duties “more likely than not” caused the worker’s disability or need for treatment. In other words, the doctor only needs to be 51% certain. However, a doctor’s note stating that worker’s disability and need for treatment “could be” or is “possibly” related to a work injury or repetitive job duties, will generally be insufficient. The law states that the doctor must give an opinion as to the cause of the disability or need for treatment based on probability, not mere possibility.
The Injured Workers’ Role in Obtaining Sufficient Medical Documentation
Because insufficient medical documentation is the number one reason claims are denied or delayed, injured workers often ask what they can do to help. Obviously, the injured worker must see a doctor as soon after the injury as possible. If the injured worker does not see a doctor, there will not be any medical documentation.
Usually, when an injured worker first goes to the doctor after an injury, he or she will have a conversation with the doctor about how the worker’s symptoms began. When a worker has a specific injury that occurs at work and the cause of the injury is obvious, the doctor only needs to describe the circumstances of the injury and will usually do so without being asked.
When a worker’s repetitive job activities causes an injury over time, or if there is a pre-existing condition involved, the doctor may not think to write down any comments about the cause of the injury. In this situation, the worker should have a conversation about this issue by asking the doctor whether it is likely that work is a cause of the medical condition. If the doctor says that it is, the worker may ask the doctor to provide a letter for worker’s compensation purposes. Most doctors will know what to write.
Sometimes, your lawyer may need to write a letter to the doctor asking specific questions about the causes and effects of your work injury. If part of a case is denied or delayed due to insufficient medical documentation, the worker may ask the doctor if it would be okay to have the lawyer send a letter with some short questions. Most doctors will gladly agree, however some may charge the lawyer a fee.
Sometimes a second opinion from a different doctor may be necessary. Doctors often disagree as to the causes and effects of a particular injury, and some simply refuse to get involved with a workers’ compensation case. Medical records are so important to a workers’ compensation case that in these situations, it may be necessary to see a different doctor.
Obtaining Medical Records
The attorneys and staff at Keches Law Group typically send letters to our clients’ medical providers requesting complete copies of their medical records. We typically do this several weeks before a court date as well as when we first open a new case. You can help by keeping our office informed of any new doctors that you see and the address and phone number where we can request medical records on your behalf. You can also help asking the doctor to provide you with periodic notes about the status of your work injury, including a comment on the cause of the injury, your current disability status, and any additional treatment you require.