Often, my doctors, when doing file reviews find that the medical records in files are incomplete. One of the more typical instances when medical records are not obtained when they could be useful to an employer is when there is a pre-existing injury or condition, the adjusters often don’t order the pre-injury records. They consider them to be irrelevant because it’s often said that “the employer buys the claim regardless of the condition of he employee” when they joined the insured’s workforce. But that’s only partially true.
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“The 6-Step Process To Determine Workers’ Comp Injury Causation”
Here are 3 examples of when pre-injury records are relevant to a claim: These records are relevant when the claimant’s acute injury resolves but an underlying degenerative process is still progressing.
1- For instance, one worker had been having a shoulder problem for 18 years. He reinjured his shoulder at work but then recovered. Six months later, he needed shoulder surgery. Because the IME physician was not asked whether the surgery would have been needed regardless of the workplace incident that had cleared up months ago, the IME physician did not address that issue and the workers compensation insurer paid for the surgery even though the answer to the unasked question was “yes.”
2- In another example, a pregnant employee reported having back pain. The medical advisor recommended obtaining notes from the woman’s obstetric visits; from these, a history of pregnancy-caused back pain was found.
3- The presence of herniated discs in the preinjury records can also be a very valuable finding for the employer. The value of a back injury claim typically rises when there is a herniated disc. However, studies show that 30 percent to 40 percent of people without a history of back pain have herniated discs. Therefore, records predating the workplace injury are essential in determining whether a herniation is indeed work-related. These examples come from a review of claims evaluated by Dr. David Dubin when determining how well the claims were handled in our Quality Control Claim Review.
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Do not use this information without independent verification. All state laws are different. Consult with your corporate legal counsel before implementing any cost containment programs.
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