An injured worker is entitled to certain benefits under the Workers’ Compensation Act. These benefits may include:
- Medical – medical care or treatment reasonably necessary for work injury.
- Wage replacement – 2/3 of usual wages if disabled due to work injury.
- Permanent impairment – if work injury causes permanent impairment.
- Vocational rehabilitation – if unable to return to suitable work.
- Death benefits – if work injury or accident results in death.
When a work injury is uncontested, the injured worker can receive their appropriate benefits as a matter of course. Alternatively, if there are doubts about the work injury or the consequences of the injury, the claim is disputed. Whether the claim is disputed or not, most work injury issues revolve around medical matters and therefore, medical records and opinions provide guidance for action. When a claim or benefit is disputed, the physician’s opinion is even more crucial. The strength and the basis of a doctor’s opinion can make or break a claim.
The following represent some critical issues in worker’s compensation. Agency determinations about each of these issues requires medical evidence, and if there is a dispute, the more persuasive medical testimony determines the outcome:
- Causation – whether or not an injury arose out of and in the course of work.
- Disability – whether or not the worker is able to work or is disabled due to injury.
- Medical end – whether the worker has improved in their recovery to the point that significant further improvement is not expected, regardless of treatment.
- Aggravation or recurrence – whether a new work injury to the same part of the body is part of a prior injury (recurrence) or if it is a worsening or aggravation.
- Necessity of treatment – whether specific medical care or treatment is appropriate.
- Permanent impairment – whether or not the injury causes permanent impairment and if so, the amount of the permanent impairment.
- Apportionment – of permanent impairment if there was a prior work injury resulting in permanent impairment.
Two examples can illustrate the importance medical evidence:
Example 1. Causation
Worker reports to her supervisor that she hurt her back lifting a heavy box at work. Her supervisor sends her to the doctor’s office. The doctor takes the worker’s medical history and indicates in his notes that the worker has no history of back problems or back complaints and the problem is new and related to lifting at work that day. These medical notes would be sufficient evidence to support a work injury claim.
Alternatively, if the medical evidence supported a prior injury with no new event or worsening, then the insurance carrier could deny the claim. Valid evidence could include pre-existing medical records that establish an ongoing back problem, or, medical records that make no mention of a work injury or any worsening due to the work event, or, medical records that indicate worker injured her back performing an activity outside of work. If there are conflicting medical records or evidence, the injured worker’s evidence must be more persuasive.
Example 2. Disability
An injured worker is entitled to disability benefits called Temporary Total Disability benefits if their physician provides written documentation that the work injury causes disability from work. The physician is considered the expert on the issue of whether or not the worker is allowed to work following an injury. It is important, however, for the physician to provide support or reasoning for their opinion.
For example, a doctor may take the injured worker out of work and label them disabled following an injury. If the worker is taken out of work for a long period of time or if the injury seems minor and not disabling, the insurance carrier may schedule an Independent Medical Examination (IME) to obtain another medical opinion concerning the worker’s medical status and disability. If the IME physician consider the worker to have limitations but an ability to work, and the other doctor disagrees, the medical evidence and opinions must be weighed.
Weighing medical evidence and opinions can occur formally or informally. Workers’ compensation hearing decisions are posted on the workers’ compensation website. Numerous hearing decisions have noted the 5-prong test which the department applies to weighing medical opinions and testimony:
- Nature and length of medical provider/worker relationship.
- Did provider have available and consider all medical and accident records ?
- Was the medical evaluation clear and thorough?
- Was the examination comprehensive?
- Experts qualifications; education, training, experience.
Medical disputes at the informal level are usually addressed by reviewing the medical records. A physician’s opinion may be bolstered or given more weight if another physician or other medical records provide corroborating medical information. Alternatively, an opinion may carry less weight or be disregarded if it is inconsistent with a previous opinion from the same or a different physician or if it does not take into account important information in the medical records. For example, a particular diagnosis may require a specific positive test or exam finding. If those elements are not present, that doctor’s opinion may be disregarded. It is important for all the medical information to be considered.
Medical providers should be aware that their opinions carry substantial weight in the worker’s claim. Some physicians may not be familiar with the workers’ compensation process. It is not necessary to know all of the terms, like aggravation or recurrence. It is more important for the physician to be aware that their notes will be reviewed and considered on important issues. Pronouncements of diagnoses, causation, disability or permanency are important but it is more important for the physician to give their reasons or state why their opinion is what it is.
It is difficult for the workers’ compensation division to disseminate workers’ compensation information to medical providers. In an effort to involve medical providers more, we are providing you an opportunity to register to receive e-mail through our medical list serve. If you sign up we will notify you when a law, rule or memorandum is issued on workers’ compensation matters that impact medical care providers. To subscribe to the list to receive announcements, click on the following link and type your email where indicated: Medical/Health Care Providers Email List