Why Medical Records Are Key When Investigating a Claimant’s Medical History

by | Published on Aug 18, 2023 | Medical Record Review

In personal injury, medical malpractice, workers’ compensation and other claims that involve a medical component, medical history plays a pivotal role in establishing the validity of the claim. Attorneys and legal teams utilize medical record retrieval services to access accurate and comprehensive medical records. These records serve as a goldmine of information that can greatly influence the outcome of a case. Liability and damages are the two main areas of focus in injury lawsuits. The major part of the claimant’s damages comprises medical treatment and to determine eligibility, insurers need to get an accurate picture of the claimant’s medical history. Claimants are required to reveal any prior medical treatment and any subsequent medical treatment they may have undergone. However, they may not always provide accurate answers to the questions. To obtain an accurate medical history, the attorney may have to subpoena all of the claimant’s past and current medical records. These records are then reviewed thoroughly to extract the required information.

Why Is Medical History Important?

Medical history plays a pivotal role in shaping insurance coverage, premiums, and overall risk assessment for both insurers and policyholders. Medical history evaluation is therefore a major consideration during a medical record review for attorneys.

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Here’s why medical history holds immense importance in the context of health insurance:

  • Risk Assessment and Premium Calculation: Health insurance companies assess the risk associated with insuring an individual based on his/her medical history. A person with a history of chronic conditions or pre-existing illnesses is considered a higher risk, as they might require more frequent medical care and treatments. As a result, insurance premiums are often adjusted to reflect the perceived risk. Individuals with a healthier medical history may benefit from lower premiums due to their lower perceived risk.
  • Policy Customization: Understanding a person’s medical history allows health insurance providers to customize insurance policies to meet specific needs. Individuals with certain medical conditions might require coverage for specialized treatments, medications, or therapies. By analyzing medical history, insurers can offer policies that align with the individual’s health needs.
  • Coverage Exclusions and Waiting Periods: Health insurance policies may have certain exclusions or waiting periods for pre-existing conditions. Insurers might not cover treatments related to conditions that existed before the policy’s inception or during a waiting period. Accurate knowledge of a policyholder’s medical history helps insurers determine which conditions fall under these categories.
  • Claim Assessment and Processing: When policyholders make claims, their medical history plays a role in assessing the legitimacy of the claim and its alignment with the policy’s terms. Insurers review medical records to ensure that the claimed treatments are related to the individual’s medical history and that they comply with the policy’s coverage criteria.
  • Underwriting Decisions: Underwriting is the process by which insurers evaluate an applicant’s risk profile and decide whether to provide coverage and at what terms. An individual’s medical history is a crucial component of underwriting decisions. Depending on the severity and nature of pre-existing conditions, insurers may approve or deny coverage, or they may offer coverage with specific conditions or limitations.
  • Policy Renewals: Changes in health status or new medical conditions might lead to adjustments in premium rates or policy terms. An updated understanding of a policyholder’s medical history ensures that the insurance coverage remains relevant and suitable over time.
  • Disease Management and Prevention: Health insurance providers use medical history to offer preventive care and disease management programs to policyholders. By identifying high-risk individuals, insurers can offer resources and support to help individuals manage their conditions and improve overall health outcomes.

Medical Records Provide a Complete Understanding of Medical History

Medical records provide a comprehensive overview of a claimant’s medical history, helping attorneys build a strong case foundation. They contain detailed information about past illnesses, injuries, treatments, medications, surgeries, and more. Attorneys can use this information to establish a clear timeline of the claimant’s medical journey, enabling them to connect the dots between the alleged incident and the pre-existing medical conditions. Here are the ways in which medical records help establish medical history.

  • Accurate Timeline Creation: Imagine a personal injury claim where the claimant alleges that a slip and fall incident at a supermarket led to a serious back injury. By reviewing the claimant’s medical records, attorneys can access information about any prior back-related issues. If the medical records reveal that the claimant had already been undergoing treatment for back pain prior to the incident, it could raise questions about the true cause of the injury.
  • Identifying Underlying Conditions: In another scenario, consider a claimant who files a medical malpractice suit, alleging that a surgical procedure resulted in a severe infection. By thoroughly reviewing the claimant’s medical records, legal teams may uncover pre-existing conditions that could have made the claimant more susceptible to infections. This information can significantly impact the assessment of causation and damages in the case.
  • Finding Contributing Factors: Medical records also help legal teams identify contributing factors that might have aggravated the claimant’s injuries. For instance, if a claimant is seeking compensation for a car accident-related injury, a comprehensive review of medical records could reveal that the claimant was already suffering from a weakened bone structure due to a previous medical condition. This information can influence the assessment of damages and the extent to which the accident aggravated the existing condition.
  • Evaluation of Treatment Effectiveness: By analyzing medical records, attorneys can understand the effectiveness of treatments and interventions the claimant received. If the records indicate that the claimant had been consistently seeking treatment for a certain condition prior to the alleged incident, it becomes essential to assess whether the treatments were showing positive results. This insight can be valuable in establishing the veracity of the claimant’s case.
  • Long-term Impact Evaluation: Medical records offer a window into the long-term impact of injuries. For instance, a claimant seeking compensation for a workplace injury might have undergone multiple surgeries and therapies. By studying the medical records, attorneys can determine how these interventions have affected the claimant’s quality of life, ability to work, and overall well-being.

Evidentiary Value of Medical Records

  • Authentic Source: Medical records are generated by qualified medical professionals in the course of providing care to patients. Their authenticity is difficult to challenge since they are created at the time of treatment and are part of the routine documentation process in healthcare settings. This authenticity lends weight to the information contained within the records.
  • Expert Opinion: Medical records include diagnoses, treatment plans, and descriptions of medical procedures. These entries are considered expert opinions in court since they are provided by medical professionals who have the necessary expertise to diagnose and treat medical conditions. These opinions can influence the court’s understanding of the claimant’s medical history and the impact of injuries.
  • Contemporaneous Documentation: Medical records are created close to the time of the medical encounter. This concurrent documentation is crucial because it captures the patient’s condition, symptoms, and treatment details accurately and objectively. Judges and juries appreciate the reliability of records that were documented in real-time.
  • Impeachment and Cross-examination: Medical records can be used for impeachment or cross-examination purposes. If a claimant’s testimony contradicts the information documented in their medical records, attorneys can use these records to challenge the claimant’s credibility. This can significantly impact the outcome of the case.
  • Corroboration of Testimony: In cases where a claimant’s version of events is supported by their medical records, these records can serve as corroboration of the claimant’s testimony. For example, if a claimant alleges a slip and fall incident resulting in a broken arm, medical records documenting the treatment and the nature of the injury can lend credibility to the claim.
  • Factual Basis for Legal Arguments: Attorneys often use medical records as a factual basis for legal arguments. For instance, if a claimant is seeking compensation for medical expenses related to an injury, the medical records detailing the treatments received and associated costs serve as concrete evidence to support the financial aspect of the claim.
  • Causation and Damages: Medical records can play a pivotal role in establishing causation and damages. They provide an objective record of the claimant’s injuries, treatments, and progress. Attorneys can use this information to illustrate the link between the incident and the claimed injuries, as well as to quantify the extent of damages suffered.
  • Expert Testimony: In complex cases, medical records may be used as the foundation for expert testimony. Medical experts can analyze the records and provide their professional opinion on the claimant’s medical history, the impact of injuries, and the causal connection between the incident and the injuries.

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It is evident that medical records act as a factual repository that allows attorneys and medical experts to objectively evaluate the claimant’s medical history. Medical history is a key consideration in health insurance, influencing policy coverage, premiums, underwriting decisions, and claim assessments. As a company providing medical record review for attorneys, we understand that a comprehensive understanding of a policyholder’s medical history enables insurance companies to provide suitable coverage, manage risk effectively, and ensure the fair and accurate processing of claims. It benefits both insurers and policyholders by creating a balanced and transparent insurance ecosystem.

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