Write a Great Workers’ Compensation IME Letter

Members of the claim management team are often called upon to write a cover letter to a doctor for purposes of an independent medical examination. This is sometimes an overlooked part of a claim handler’s job. Care should be taken to writing an effective letter as it will help at later points of the claim, including future litigation.

Important Points of Consideration

The cover letter for an independent medical examination is an important part of a claim. The person drafting the letter should consider the following matters:

• The cover letter sent to a medical expert is subject to discovery protocols. Make sure the letter is free from bias, written in a manner respectful of the injured worker and completely factual;
• Letters to medical experts should be clear and concise. Avoid adding unnecessary information and your personal opinions; and
• Make it clear as to the procedural posture of the case and let the medical expert know what findings and opinions are seeking.

Laying Proper Foundation

In order for expert testimony to be accepted, the examining doctor needs to have the requisite medical background. They also need to demonstrate they have seen and examined the injured worker and have a complete set of facts. A great IME cover letter will help the expert do this.

• Provide the doctor with a complete background of the case on the body of the letter; and
• Provide the expert with a complete set of medical records. List the records you are sending to the doctor in the body of the record. It is also important to request the doctor re-state the records they reviewed in the final report.

Issues of Causation and Need for Medical Care

Remember that workers’ compensation cases typically have a lower threshold of compensability when compared to other personal injury cases. Consider asking the expert the following questions:

• What is your diagnosis and prognosis of the Employee’s complaint(s)?
• What is the substantial contributing cause of any diagnosis you make? Further, what is the etiology of any diagnosis you make?
• In your opinion, did the claimed events of DATE OF INJURY HERE, aggravate, accelerate or otherwise substantially contribute to the onset and progression of the Employee’s diagnosed condition?

Always Ask About Maximum Medical Improvement/End of Healing Period

Maximum Medical Improvement (MMI), or “end of healing period” is an important threshold in workers’ compensation cases. In most jurisdictions, it can signal the end of a claimant’s temporary total disability (TTD) benefits. It can also serve as a basis for rating any permanency.

Here are some suggested questions to consider:

• In your opinion, has the Employee reached Maximum Medical Improvement for all diagnosed conditions? If so, when did the Employee reach Maximum Medical Improvement? If not, when would you expect the Employee to reach Maximum Medical Improvement for all diagnosed conditions?
• Do you agree or disagree with Dr. NAME HERE’s opinion, found in the medical records from PROVIDER NAME, dated DATE HERE, which the Employee reached Maximum Medical Improvement on DATE HERE? Why or why not?

Be Careful When Asking About Permanency Rating

Asking about a permanency rating can be detrimental to a case when asked in the early phases of litigation. Be sure to consult with your attorney or others on your team when asking the following:

• Did the Employee sustain any ratable permanent partial disability, pursuant to the STATE NAME Workers’ Compensation Permanency Guidelines as a result of the work injury of DATE HERE? If so, please state what would you attribute any permanent partial disability, citing the specific section in the STATE NAME Workers’ Compensation Permanency Guidelines?

When in doubt, simply ask the examining doctor to evaluate for this issue, but defer stating these opinions in writing.

Other Questions to Consider

There are also other matters to consider when obtaining an independent medical examination.

• The reasonableness/necessity of prior medical care and treatment;
• Whether all prior medical care was in conformance with any applicable treatment guideline;
• Any future medical care and treatment that maybe related to the work-injury;
• Issues regarding appropriate medical restrictions on the employee’s activity;
• Matters concerning future employability and permanent total disability issues.

Before asking these questions, consider your case and the purpose of the examination. Asking non-germane questions may open matters for additional claims.

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms, he is in the trenches on working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: [email protected].

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.