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What Role Does Medical History Play in a Workers’ Compensation Claim?

Workers’ Compensation

Medical history is very important in a workers’ compensation case, and injured workers have to disclose their entire medical history to the workers’ compensation physician to avoid complications during the medical claims review stage. Typically, a worker’s pre-existing illness can complicate a claim, and a health condition that pre-dates the workplace injury could affect the benefits the worker receives. If the prior condition is medically related to the claim, the benefits may be affected more severely. For instance, if a worker with a history of knee arthritis suffers a knee injury at work, his benefits could be more affected compared to another worker who underwent a hip surgery earlier, and at present suffers a knee injury at work. In most U.S. states, employers are responsible only for the worsening of a worker’s physical condition caused by the workplace injury, and not for any concern caused by the pre-existing condition.

Prior Medical History an Important Consideration

As mentioned earlier, the employee must be truthful when answering questions about his/her medical history or prior illnesses/injuries. This is important not only from the point of view of receiving appropriate treatment, but also from that of getting the due workers’ compensation benefits. An incomplete or inaccurate medical history can have a negative impact on the workers’ compensation claim. Sometimes, workers do not reveal some details of their medical history. This happens when they are worried that their employer may find out about past illnesses/injuries and their claim may be denied if there have been similar injuries in the past. However, if the insurance adjuster finds out about the prior health conditions, the physician may no longer consider the claimant trustworthy and may not support the claim anymore.

Why a Complete Medical Chart Is Significant

In most states, the employer/insurer may be entitled to receive information regarding the claimant’s entire medical history. This is in order to evaluate the compensability of the workers’ compensation claim. They perform a medical records review to find out whether the worker had earlier injuries to the body part injured in the workplace accident, or any prior conditions such as high blood pressure or diabetes. Investigating prior injuries is immensely significant for the employer or insurer because they may not be responsible for payment of medical treatment for an injury that occurred before the workplace accident, and/or did not occur in the course and scope of the worker’s employment. Pre-existing health conditions can compromise an injured worker’s recovery or slow down healing. In such instances also, the employer/insurer may not be held responsible for reimbursing the treatment costs.

The worker’s medical records are important to the employer/insurer also because they provide information about the injured employee’s communications with his/her medical providers. Though generally such communications are confidential, in a workers’ compensation claim where the injured worker is seeking medical treatment for a workplace injury, those conversations are no longer confidential.

An insurance company or judge considering reimbursement for an injured worker’s medical treatment would be looking for medical documentation regarding the type of treatment that the physician is recommending. They would also be looking for documentation that states that the employee requires the treatment for a medical concern caused by the workplace injury or his/her repetitive job duties.

According to a kecheslaw.com/ article,

  • In the case of injured workers with pre-existing conditions or other medical issues that could be partially responsible for their disability or need for medical treatment, the insurer or judge would be looking for documentation that states that the specific work injury or repetitive job duties are “a major cause” or “a significant factor” in bringing about the impairment or the need for medical treatments.
  • The work injury needn’t be the only cause of a disability or need for treatment for the worker to receive compensation.
  • If the treating doctor is uncertain regarding the actual reason for the injury, the injured worker may be still entitled to workers’ compensation benefits, provided the doctor explains that the work-related injury or repetitive job duties “more likely than not” caused the worker’s impairment or need for treatment. The doctor must give an opinion regarding the cause of the disability or need for treatment based on probability and not a mere possibility.

Pre-existing conditions and past medical records cannot be ignored in a workers’ compensation claim. A medical claims review company assisting workers’ compensation attorneys focuses on retrieving all applicable medical records, both past and current so that a clear evaluation can be made. Incomplete or insufficient medical records are the number one reason why claims are denied. A complete medical chart is vital to ensure appropriate medical treatment to the injured worker, and also to avoid unnecessary payments by the insurer. A worker who has been previously awarded workers’ compensation benefits for an injury and is now suffering a worsening of the original injury may not be eligible to file a new workers’ compensation claim, though he/she may be able to reopen their earlier case.

Disclaimer: The content in this blog is sourced from reliable internet resources and is meant for informative purposes only. For a professional opinion on this topic, consult a workers’ compensation attorney.

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