What Medical Documentation Is Needed To Support A Workers’ Compensation Lawsuit?

by | Published on Aug 17, 2022 | Workers Compensation

The proof of injury suffered by the claimants in workers’ compensation lawsuits lies in the medical records or medical documentation. In this way, medical record review for attorneys is crucial in deciding the merits of the case. When an injury is first reported to the concerned insurance company, they have to decide whether to pay or deny the claim within fourteen days. It depends upon the medical data of the claimant provided by the attorney to the insurance company. If the workers’ compensation claims are denied, a legal case has to be filed against the insurance company. At every stage of the litigation, the medical documentation of the claimant is vital to support the arguments. In this blog, we shall look into the medical documentation that has to be furnished in workers’ compensation claims.

What is Medical Documentation and Why Is It Essential?

  • Medical documentation can be written or typed treatment notes prepared and signed by the treating physician. It is designed after examining a patient and consists of the details regarding the injury suffered by the patient along with the existing medical conditions. This data is fundamental for pointing out the cause of the injury and developing claims around it.
  • The claims submitted have to align with the medical documentation to ensure that the claimant gets the eligible compensation from the insurance companies. It implies that any discrepancy in the medical records and the statements put forth by the attorneys can lead to claim denials. Medical documentation proves the medical necessity of a particular procedure or treatment and its coverage by insurance companies.
  • The medical history of the client mentioned in the medical records shows whether there was any pre-existing medical condition. With reference to recordrs.com, in most US states, insurance companies cover only severe medical conditions caused due to work-related injury or illness and don’t cover any pre-existing conditions, if any. If the workers’ compensation claim is related to any pre-existing medical condition, then it is likely to affect the eligibility for certain benefits.
  • For instance, if the claimant has a history of lung disorder, inhalation of poisonous gases from the work site can exacerbate the condition. In such claims, the treatment costs are not covered as the pre-existing conditions are considered as the contributing factor that leads to the exacerbation of the work-related injury or illness.

Medical review solutions can assist attorneys in organizing and sorting medical records at every stage of the litigation, depending on the requirement.

Medical Documentation Required To Support A Workers’ Compensation Claim

The benefits of workers’ compensation claims include:

  • Paying the injured worker for medical treatment
  • Paying weekly wages for the injured

When an insurance company or a judge is considering paying for the medical treatment of the injured worker, the documentation must have the type of treatment recommended by the doctor. It should also mention that the claimant needs treatment for addressing the medical condition that occurred due to the nature of work. The injury can be specific or injury that was caused due to the claimant’s repetitive tasks at the workplace.

For paying lost wages, the documentation has to specify medical grounds for the claimant's work disability. The medical restrictions that prevent the physical movement of the claimant will be clearly mentioned in the medical documentation. The treating physician might provide restrictions like ‘no lifting’ and ‘light duty only’ in the documentation. The documentation has to mandatorily mention that the disability was caused due to either specific work or the repetitive tasks done by the claimant.

So, what should the medical documentation include?

  • The medical history of the patient assists attorneys to convince the judge that the claimant has no prior medical condition that led to the work-related health condition.
  • Clinical observations and results of the physical examination of the claimant ascertain that it conforms with the standard of practice of similar health care providers, with similar training, in the same or similar communities.
  • The medical documentation has to reflect the progress, clinical, or office notes. It has to include the complaints of the patients and the observations of the provider about the health condition of the claimant.
  • Objective assessment of the present health condition of the patient.
  • The treatment plan and updated assessment of the patient.
  • Diagnostic and lab reports.
  • Response to the treatment and medicines administered.
  • The inpatient and outpatient records of the hospital like operation reports, test results, consultation reports, discharge summaries, and dictated reports of the physician.

A medical record review company can ensure that the medical documentation is accurate and relevant with detail-oriented patient information. This allows attorneys to focus on time-sensitive workers’ compensation cases.

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

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