On many occasions, members of the claim management team need to write a cover letter to the independent medical examiner. This is an important part of defending a workers’ compensation claim for mean reasons. It includes preparation, planning and having accurate information. When drafting this letter, it is important to consider a number of factors and include the right questions.
Expert Foundation for Medical Opinions
It is important that your expert has the proper foundation to provide their findings and opinions within a reasonable degree of medical certainty. As part of your cover letter, consider asking for the following information:
- Please set forth the amount of time that you spend with «Name of Employee» in your evaluation.
- Please set forth the medical records which you reviewed as part of your evaluation.
Information on the Injury and Its Nature and Extent
It is important to demand precision for your medical expert. Help ensure you receive the information you need by asking for the following:
- What is your diagnosis and prognosis of «Name of Employee»’s «Body Part/Condition»?
- What is the substantial contributing cause of any diagnosis you make? Further, what is the etiology of any diagnosis you make?
If there is a question as to whether the work activity contributed to the condition, you might want to consider asking:
- In your opinion, did the claimed events of «Date Here,» aggravate, accelerate or otherwise substantially contribute to the onset and progression of «Name of Employee»’s diagnosed condition?
Otherwise, it is important to verify the condition is work related, along with its nature and extent.
- In your opinion, did «Name of Employee» sustain a work injury on «Date Here»? If you find that «Name of Employee» sustained a work injury on «Date Here,» was that injury permanent or temporary in nature? If temporary, how long did it last?
- If there is more than one substantial contributing cause to «Name of Employee»’s condition, please apportion responsibility for any medical care and treatment, surgery, disability and permanency for these injuries.
Other Matters to Consider
The IME can be used to determine a number of other legal issues. Maximum medical improvement or the “end of healing period” is one of these important matters for the expert to address. The payment of ongoing benefits can depend on this status. Be sure to consider asking the following:
- In your opinion, has «Name of 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?
Issues concerning permanent partial disability are also important to consider asking about:
- Did «Name of Employee» sustain any ratable permanent partial disability, pursuant to the workers’ compensation permanency guidelines as a result of the work injury of «Date Here»? If so, please state what you would attribute any permanent partial disability, citing the specific section in the workers’ compensation permanency guidelines?
The need for future medical care and treatment is also important. Be sure to ask about the following matters:
- Has «Name of Employee»’s medical care and treatment been causally related to the (claimed events) events of «Date Here» to his/her «Body Part/Condition»? Why or why not?
- Has «Name of Employee»’s medical care and treatment been appropriate under the workers’ compensation treatment parameters (if applicable)? Why or why not?
- What medical care and treatment do you propose «Name of Employee» undergo, if any? Also, could you please state what its frequency and duration would be for any recommendations that you have.
- Is «Name of Employee» in need of any restrictions on his/her ability to perform activity, if any? If so, please state what restrictions you would place on «Employee»’s activity. Also, please state what you would attribute the need for any such restrictions?
- In your opinion, is «Name of Employee,» capable of sustained gainful employment with regard to his «Injury Here,» and if so, what restrictions, if any, would you place on his work activities?
- Is the Employee undergoing functional overlay for secondary gain?
- Please provide any additional relevant comments.
A well-written independent medical examination letter is clear, concise and free from bias. Remember that any letter sent to a medical expert is discoverable and can be submitted as evidence. By following these guidelines, members of the claim management team can ensure their expert’s opinion receives full consideration from a compensation judge.
Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a 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 & lead trainer of Amaxx Workers’ Comp Training Center .
Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/
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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.