Understanding Medical-Legal Evaluations - Part 1

Sunday, November 24, 2002 | 0

A workers' compensation case is very similar to other legal proceedings in that decisions are made based on evidence provided to a decision maker. In workers' compensation, the vast majority of that evidence is medical information.

This information is typically presented to the decision maker (administrative law judge) in the form of a report, or what is commonly known as a "medical-legal" report. This report is generated following an examination of you, and a review of the medical documentation that had been generated prior to your evaluation.

Medical-legal evaluations may be ordered by your attorney to prove a disputed medical fact in your favor. Alternatively, the insurance company may order a medical-legal evaluation to obtain evidence to support their position. How you prepare for your medical evaluation, and how you conduct yourself during your evaluation, can greatly impact the outcome of your case. You need to understand why a particular exam is being requested, and how it is anticipated that it will be used.

The medical-legal examination is typically for obtaining opinion about the nature, extent and likely cause of an illness or injury that is the subject of a compensation claim. Issues that may be covered in such an examnination include whether the injury or illness was in any way caused or contributed to by your work, how long you need to stay off work to recover, what kind of medical treatment would be most appropriate, whether treatment in the past has been reasonable and/or necessary, whether any pre-existing condition has anything to do with your current condition, and what the level or permanent disability may or may not be (including restrictions on the amount of nature of work you can do after maximum recovery).

The person who is asked to provide this opinion is usually a specialist in a field relevant to the condition involved. In most states, the insurer pays for this visit to a specialist as well as paying reasonable costs associated with the visit (such as any diagnostic studies requested by the physician or your transportation to and from the examination).

You are likely to be asked to attend a medical-legal appointment if your case is litigated (or contested) so it is important that you have a clear understanding of your rights and obligations in such a circumstance.

In some states, a very important right that you may have when attending a medical-legal appointment is to be accompanied by a witness of your choice. Typically though, if you do have this right, before you can take along a witness you must inform the insurer of this in advance, and typically the physician as well. Some physicians will object to the presence of a witness because they feel it will compromise your privacy and may result in less than candid responses to sensitive questions. If the specialist will not conduct the examination with a witness present, then another appointment needs to be scheduled with one who will.

If you are accompanied by a witness, it is important that they clearly understand the role of the witness and are competent to carry it out. Witnesses should not interfere with the examination and are there to ensure that they can provide satisfactory evidence in court, should there be any subsequent dispute arising from the medical examination. You could discuss your choice of witness with your legal representative.

One of your rights concerns your access to information about your case. It is important that you prepare for the examination by reviewing all the information about you that the insurer provides to the examiner, both written and verbal. You have a right to see the letter the carrier sends to the physician which will detail the points that the carrier wants the physician to focus on in the examination and report.

You should be very familiar with all of the medical documentation that is being supplied to the physician: other medical reports generated in your case, subpoenaed medical records, witness statements and any other documentation. A list of the evidence being delivered to the physician is typically a part of the letter from the carrier. If not, ask for that list.

A medial-legal report is only as good as the facts upon which it is based. If the physician does not have a complete set of facts, be it about how the injury or illness came about, your past medical history, or your current abilities, then the medical report may be flawed enough that it cannot be considered as good evidence. While you may think this is okay for the insurance company's report, in fact you want to be sure that the carrier's physician is just as fully apprised of all facts and circumstances as your physician otherwise your case may be delayed because the insurance company will charge you with not being fully honest and will demand (and usually get) a fresh examination. In the worst case you could be accused of fraud and your case thrown out.

After the insurance company has obtained their medical report you need to review it carefully, especially any statements of a historically factual nature. You may consider that some of that information is incorrect, out of date, ambiguous or inappropriate. If so, it may be necessary for your attorney to write to the insurer pointing out the contested information and, depending on its nature, perhaps suggesting that it may reduce the capacity of the examiner to provide an independent opinion.

In our next article in this series we will review the medical-legal appointment itself, what you can expect and how you should conduct yourself in the face of this examination.