Does Workers’ Compensation Cover Soft Tissue Injuries?

by | Published on May 23, 2018 | Medical Peer Review, Record Retrieval Services

Workers’ compensation insurance covers most on-the-job injuries and illnesses related to one’s work. Attorneys handling workers’ compensation cases utilize the service of medical record retrieval companies to collect all relevant medical records that are required to prove the injury or illness. Medical peer review, which is a key component of UR or utilization review is used by the insurer to help ensure that patients receive medically necessary care based on evidence-based guidelines. One of the workplace injuries covered by workers’ comp is soft tissue injury. This injury is the damage of muscles, ligaments, and tendons throughout the body, and common soft tissue injuries occur from a sprain, strain, or a blow to a particular part of the body. The benefits available to the injured worker for a non-surgical soft tissue injury are limited to “appropriate and necessary medical care and temporary and total disability.”

What are the different types of soft tissue injuries?

  • Sprain – When a ligament could be stretched or torn
  • Contusion –Bruise caused by a blow to the muscles, ligaments or tendons
  • Strain – Involves stretching or tearing a muscle or tendon
  • Tendonitis – Here a tendon or the covering of a tendon is inflamed due to repeated stress
  • Bursitis – Swelling and irritation of the bursa in the shoulder, hip, elbow, knee or ankle
  • Stress injuries: These could be small breaks in a bone caused by stress through overuse.

Many workplace injuries fall under soft tissue injuries. Such injuries are usually caused by the following reasons.

  • Overexertion that includes injuries associated with lifting, pulling, holding, pushing, throwing or carrying something.
  • Fall on the same level or to a lower level
  • Struck by objects such as falling tools or other materials
  • Trapped in or compressed by objects/equipment
  • Car or truck accident
  • Repetitive motion injuries because of repeated stress or strain
  • Violent act/assault

Though relatively minor workplace injuries, soft tissue injuries should not be overlooked.

Workers’ compensation typically covers injuries that are physical. Treatments for psychological trauma/injuries will be covered if the condition is diagnosed as stemming from the initial physical injury. This policy varies from state to state. Many states don’t cover an injury that is only psychological and not physical. However, states will consider a claim of psychological injury based on the federal regulations for a psychological claim. The following aspects are to be established.

  • The event occurred while performing work or some other activity related to work
  • The event triggered the psychological condition
  • A medical diagnosis has been made of the psychological condition
  • The medical diagnosis establishes a connection between the event, situation, or allegation to the psychological condition
  • The claim must be filed within the same regulations governing physical injury claims

Workers sustaining soft tissue injuries may be eligible for permanent disability benefits if they have not made a complete recovery from their injury once it has stabilized. This type of disability may refer to varying degrees of disability. The treating doctor will determine the percentage of disability based on the AMA’s (American Medical Association) standards. To receive full benefits, the injured worker must be evaluated at 100% disabled. The insurance company covering the employee’s worker’s compensation benefits will cover reasonable medical care associated with the treatment of his/her permanent disability. Workers’ compensation attorneys and their assisting medical records review companies know that workers who sustain an injury that they believe has permanently disabled them, should establish that with a medical professional using the AMA standard, which is highly regarded by state and federal courts, workers’ compensation review boards, and insurance companies.

Discover our medical record review solutions and partner with us for your next case.

Related Posts