Insurance companies regularly refuse to pay for medical care for an injured person because they question whether the treatment is related to the injury or because they think the treatment is unreasonable and/or unnecessary. Judges regularly refuse to pay benefits to disability claimants because they conclude that the claimant’s medical records do not support or match what the claimant is saying.

As a result, most of our clients require the support of their medical providers in order to obtain the benefits to which they are entitled. This medical support can take the form of your medical records, completing a form or questionnaire, or a letter responding to questions that we send them.

Medical Records

Medical records are usually very important to a claim. People should always be honest and thorough when talking to their medical providers. What those providers write down in the chart may be a big deal to a claim. When someone sees a medical provider, it is important to tell each and every medical provider about all medical problems. One way to do that is to simply bring a list of current medical problems and symptoms to each medical appointment and explain, “I want to be accurate about what’s going on with me.” If someone has functional problems because of their medical conditions (such as limitations in standing, lifting, sitting, reaching, paying attention, listening, etc.), it may also help to provide that information to the medical provider as well.

Even when the patient is being honest and thorough, medical records can still be inaccurate and/or incomplete. For example, many medical providers do not have the time to talk to a patient about all of the patients’ medical problems, and instead limit a visit to what is most important at that time. Unfortunately, insurance companies, juries, judges, and other decision makers may conclude that if a medical record does not mention a particular medical condition or symptom, then the patient must not have been experiencing that condition or symptom at the time of the visit.

Additionally, many computerized medical record systems include routine form entries that can be misconstrued by others. For example:

  • If the history or social section of a patient’s chart note says that the patient is still working (even though the patient hasn’t worked in years), then that person’s disability claim may be denied on that basis alone. Many medical providers do not update this information very often (or at all) because it’s not important to them, but other people may not know that and assume that it’s accurate.
  • If a medical provider writes down “no complaints,” then third parties may conclude that the patient was not having any problems that day. When this problem is pointed out to the patient, the patient may explain, “well, I didn’t tell my primary care physician about my knee problems because I see an orthopedist for that.” But, many factfinders (judges, insurance companies, juries, etc.) do not make those distinctions and may simply conclude that that patient is not credible.

If you discover that your medical records are incorrect or incomplete, you should contact the medical provider. Most medical providers have people who can help you with this issue. It is not something your lawyer can do for you, unfortunately.

Medical Provider Opinions

Regardless of what someone’s medical records say, we sometimes need to get more information or a clarification from a medical provider. That can take the form of a questionnaire or form, or a letter response. Unfortunately, many medical providers are not willing to support their patients by filling out a form or writing a letter for a variety of reasons.

REASON #1: “I can’t answer this because I am not an expert/I am not an occupational medicine expert/I don’t know enough.”

If a medical provider (a doctor, nurse, physical therapist, chiropractor, etc.) has provided someone with medical care, then under the law, that provider is a medical expert who is qualified to talk about that person’s medical treatment and conditions. It is just that simple.

A medical provider does not need to be an occupational medicine specialist or have been treating someone for many years in order to have an opinion about a patient. A medical provider can simply give us their opinion (not a fact – the provider does not even have to be 100% certain) about a patient and their medical care.

Additionally, it may be no fault of the patient’s that they have been unable to see an occupational medicine specialist or someone that might be considered more knowledgeable. Occupational medicine treatment is frequently not paid by personal/private health insurance. Many patients lack the resources to effectively navigate the health care system in order to consult with what might be considered the “right” providers.

REASON #2: “I don’t want to get involved – I hate testifying.”

This is a fair point. Nobody likes being examined under oath; it can be stressful and most people have better things to do. But, it is sometimes part of the job, as an injured or disabled person might need help in obtaining benefits to which they are entitled under the law. If someone’s medical condition or injury requires explanation or clarification, that person’s medical provider is the best (and sometimes only) person to do so.

Additionally, the odds of a medical provider having to testify in any given matter are not only slim but also are unaffected by whether an opinion is given or not.

Most workers’ compensation and bodily injury claims settle. Social Security and short- and long-term disability claims do not even allow for the actual testimony of a medical provider.

Additionally, anybody can subpoena a medical provider. Defense attorneys will sometimes subpoena a medical provider who has NOT given an opinion on the suspicion that the provider does not support the claimant’s case.

REASON #3: “I don’t want to tell the truth because then my patient will get mad at me.”

We are certainly asking medical providers to tell the truth. It may be that a medical provider says something that does not help a claim. While that is too bad, it is not any worse than the provider refusing to respond. We are obligated to advise our clients of the effects of non-cooperating medical providers on a claim. Sometimes we have to tell people that they have no claim because their medical provider is not responding to questions.

REASON #4: “I don’t have time/I don’t like lawyers/I don’t ‘believe’ in lawsuits/I just don’t want to.”

There are several excellent reasons for a medical provider to help a patient in a claim.

First, we certainly understand that medical providers are busy, and try not to have any last minute emergency requests so that the providers can respond in due course. And, claimants are generally agreeable to paying a medical provider for the time and money in responding to the questions.

Surely medical providers try to avoid letting their personal predilections interfere in their care for their patients.

It should be undisputed that a medical provider is supposed to help the patient. Answering questions about the patient’s medical condition in an honest and truthful manner can allow the patient to obtain additional medical care and other benefits to which they are entitled under the law. Medical providers are generally supportive of access to medical care (and getting their own facility’s bills paid).

Finally, a medical provider who responds to questions about a patient’s functional limitations is complying with the policies of the American Medical Association (“AMA”). Here is a link to the AMA policy on “Impairment and Disability Evaluations:” AMA Policy on Impairments and Disability Evals