Writing a Decent Med-Legal Report - Part 5

Saturday, August 2, 2003 | 0

Our earlier articles on writing a decent medical-legal report essentially presumed that the physician was dealing with an accepted, compensable claim. There are, quite often however, occasions where the injury is not clearly of industrial origin, giving rise to questions of causation. This is especially true in disputed cases, where there may be some evidence of non-industrial causation, and the carrier, based on that evidence, has denied the claim. In these situations it is imperative that the physician have not only a sound understanding of the historical allegations of causation, but also a complete understanding of the principals of causation as applied to workers' compensation.

There are two types of causation: medical causation and legal causation. Legal causation addresses questions such as whether the employee was engaged in employment duties at the time of injury. Medical causation addresses whether the incident in question generated a disability or need for treatment. For the most part, physicians are not engaged to comment on legal causation since (a) it is not a medical area of expertise, but rather a legal area of expertise, and (b) physicians are not usually asked to stand in as a trier of fact and judge credibility.

It is important for the medical practitioner to remember that medical causation in workers' compensation is for the most part irrelevant to injury, unless it is a psychiatric claim. Causation in workers' compensation cases deals essentially with disability. Other than psychiatric claims, which are governed by a separate statute, the employer takes the employee as he or she is.

If the employee shows up at work with complaints from a twisted knee due to weekend sporting activities, and exacerbates that injury getting up from his desk at work, the employer is liable for the medical treatment. Even though this is an exacerbation of a prior non-industrial injury, for workers' compensation purposes, it is a NEW injury. The key is whether or not getting up from the desk was sufficiently traumatic enough to produce some injury.

How is 'injury' defined in such an event? An injury for workers' compensation purposes either causes disability or gives rise to a need for medical treatment beyond first aid. In the case at hand, if rising from the desk produced sufficient pain such that the employee could not work, there would be an injury as defined by the workers' compensation laws.

The Industrial Medical Council's Physician's Guide (download is over 4mb) counsels that while physicians provide crucial input into the system by defining the injury and in establishing whether, and how, the injury is related to the employment, they do not usually provide information regarding the employment relationship or whether the injury occurred in the "course of employment". The physician needs to assume that the facts as presented in the history of the injury are accurate, and base medical causation on those facts.

Closer cases will occur where the employee has a pre-existing medical condition, such as heart disease. Again, the rule is that the employer takes the employee as is. Physical exertion may be contra-indicated for a man with heart disease. A coronary event that occurs after physical exertion at work will generally be found to be compensable, regardless of the fact of the pre-existing heart disease, entitling the employee to treatment on an industrial basis.

Too many medical reports, and in particular, medical reports authored for the defense, fail to make this fine distinction, and erroneously conclude that there is no industrial causation. As a consequence the medical report is not substantial evidence and is thrown out. The better report will identify medical causation as an event at work that exacerbated a pre-existing condition, but apportion any permanent disability to the pre-existing condition.

One of the factors that critics have cited as a reason for escalating costs in workers' compensation is litigation. Though the system is complex, which in itself gives rise to litigation, another contributing factor to protracted litigation are medical reports that fail to address causation properly within the medical context. If the medical report affords the parties a reasonable basis for resolving the medical disputes, permitting the case to be resolved earlier, then the practitioner has performed superior service which will ultimately be rewarded.

Earlier Articles - Writing a Decent Med-Legal Report:
Part 1
Part 2
Part 3
Part 4