The wise workers’ compensation adjuster during the initial investigation of the claim ties down the nature and extent of the injury. By limiting the medical treatment to the work-related injury that occurred, the adjuster prevents additional medical treatment for preexisting medical problems from being brought into the claim. In doing so, medical treatment is limited to what is necessary and due to the work-related injury.
The medical provider will obtain from the injured worker a description of how the accident happened. The medical provider assesses the nature of the injury and makes a determination if the accident caused the particular injury. For workers’ compensation coverage to apply there must be a direct relationship between the description of the injury and the medical diagnosis.
Second Injury During Recuperation Frequently Contentious Issue
The causal relationship between the accident and the injury is seldom a point of contention in workers’ compensation claims. However, when a second medical condition develops after an injury, the causal relationship between the original injury and the second medical condition is frequently a contentious issue that requires a significant amount of medical investigation by the adjuster. The simple fact that the second medical condition developed during the injured employee’s period of recuperation does not make the second medical condition compensable.
Examples of causal relationship medical questions that are frequently disputed include:
• An employee has an injury to a foot, ankle, leg or knee that creates an alter gait, causing the employee to have back problems
• An employee injures the dominant hand/upper extremity causing the employee to over use the other upper extremity resulting in strain/sprain to the non-injured upper extremity or shoulder
• An employee suffers a torn disc or a spinal herniation, causing pain and later develops fibromyalgia
• An employee suffers a hand fracture, has a very low pain threshold and does not use the injured hand which develops reflex sympathetic dystrophy
• An employee taking a prescription drug due to the injury develops a bad side effect from the medication
Request An Independent Medical Evaluation For Second Medical Condition
Any time a second medical condition is introduced into a workers’ compensation claim and the treating medical provider indicates there is a causal relationship between the original medical condition and the new, second medical condition, the adjuster should request an independent medical evaluation (IME) or peer review.
The IME doctor or the peer review doctor will need a significant amount of information to determine whether or not the second medical condition is related to the original medical condition. Included in the information that the IME or peer review doctor will need is:
• A detailed description of the accident which caused the injury
• A copy of all prior medical records for this injury
• A copy of all prior medical records, both injuries and diseases, of the employee for 10 years prior to the accident
• A detailed description of the employee’s job duties (never rely on the employee to advise the physician of the job duties)
Along with all documentation provided to the IME or peer review doctor, a list of questions about the causal relationship should be given to the doctor to answer. This includes:
• Is there medical evidence within a reasonable degree of medical certainty to establish a causal relationship between the original injury and the second medical condition?
• What is the medical rationale explaining the relationship between the original injury and the second medical condition?
• Was the second medical condition preexisting? Was it aggravated or accelerated by the original injury?
• Is the second medical condition permanent or temporary?
• Is the IME/peer review provider’s medical opinion conclusive or is there an element of speculation as to the causal relationship?
From the adjuster’s standpoint, the IME doctor’s or peer review doctor’s report needs to be conclusive on the causal relationship or lack of relationship between the original injury and the second medical condition. If the IME doctor’s or peer review doctor’s report states “could be related” or “uncertain” as to the causal relationship, the adjuster will be unable to properly accept the second medical condition, and it should be denied.
Detailed Investigation is Required
The determination of the causal relationship of a second medical condition is frequently resolved by the workers’ compensation board or industrial commission. It is imperative for the adjuster to do a detailed investigation into the medical relationship between the original injury and the second medical condition before accepting or denying the additional medical issue. If the employee’s treating doctor and the IME doctor disagree on whether or not there is a causal relationship between the original injury and the second medical condition, another independent medical evaluator agreed to with the injured employee is an alternative approach to a board decision on the issue.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com.
Editor Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.
©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.
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