A Review Of Terms And Issues Used In Workers’ Compensation Claims
This Journal has looked at a number of issues and terms of art used to consider medical evidence in Workers’ Compensation claims. This article is a quick review of some of these concepts, with references to past issues which discuss these matters in more detail.
Medical evidence is critical in deciding these issues:
- Diagnosis of the claimed injury or condition;
- Medical causation – whether the work incident or exposure caused the claimed injury or condition;
- When and under what work situation the claimed injury/condition occurred – to decide which employer or insurer is responsible;
- Aggravation or new injury;
- Temporary Total Disability (TTD); and
- Permanent Partial Disability (PPD).
When your patient’s attorney asks you for a report or for your opinion, the attorney should briefly, clearly and directly describe:
- the issue;
- the medical questions that need to be answered;
- the level of proof required in your answers.
If these are not clear to you, please do not hesitate to ask.
If you are asked whether a particular work injury/incident caused a particular medical condition (to determine if the injury is compensable) and the worker has no preexisting condition, this terminology is required: “Within reasonable medical probability, the work injury was a material contributing cause of… (your diagnosis). The diagnosis is supported by the following objective findings…
Objective findings, which are needed to support your diagnosis, are defined as findings which are reproducible, measurable or observable. Your patient’s “subjective” responses may be objective findings if, for example, tenderness to palpation is reproducible from one office examination to another. (See Medical-Legal Journal, Vol. 1, p. 2.)
If the worker did have a “preexisting condition,” the major contributing cause standard goes into effect. A preexisting condition is any injury, disease, congenital abnormality, personality disorder or similar condition that contributes to or predisposes a worker to 1) disability, or 2) need for treatment.
If … there was a preexisting condition, and … the work injury at any time combined with the preexisting condition to cause or prolong disability or need for treatment then the combined condition is not compensable unless: the work injury is the major contributing cause of the disability of the “combined condition,” or the need for treatment of the combined condition.
So, a doctor will be asked for opinions on the following:
- Was there a preexisting condition? If so, what was it?
- Did the work injury combine with the preexisting condition? If so, …
- Was the work injury the major contributing cause of the need for treatment of this combined condition? Or…
- Was the work injury the major contributing cause of the disability of this combined condition? (See Medical-Legal Journal, Volume 3, P. 1; Volume 4, p. 1; Volume 5, P. I and Volume 9, p. 2)
Responding to the major contributing cause question calls for a two-part analysis: 1) was the causal role of the injury predominant or more than 50%, that is, more than all other potential causes combined? and 2) Compare and analyze the relative causal contribution of all other potential causes.
It is helpful to recognize that if the injury was the major contributing cause of the combined condition itself, it was also the major contributing cause of any need for treating that condition or any disability flowing from that condition.
However, it is important to note that the injury need not be the major cause of the combined condition for the combined condition to be compensable. One need only show that the injury was the major cause of the (present, post-injury) need for treatment of or the disability of the combined condition. The injury may have been the major cause of the disability or need for treatment without having been the major cause of the combined condition itself!
Recognizing these distinctions is critical to rendering an opinion which accurately addresses questions of causation where the “major cause” standard is applied. (See Medical-Legal Journal, Volume 4, p. 1; and Volume 7, A 3.)
An occupational disease is:
- a disease or infection from dust, fumes, vapors or other external substances the worker was exposed to at the work-place; or
- a mental disorder resulting from work exposure;
- a gradual onset condition (e.g. carpal tunnel syndrome, tendinitis, arthritis) resulting from work activity, usually repeated micro-trauma.
To prove an occupational disease, a physician must state: Within reasonable medical probability, the work exposures or exertions constituted the major contributing cause of the … (diagnosed condition).
Again, the doctor must compare all non-work exposures and exertions and state that the occupational exposure was greater than all other potential exposures combined.
Understanding the legal significance and application of these terms will help insure that your reports, responses to inquiries and testimony accurately address the issues crucial to the outcome of your patient’s Workers’ Compensation claim.
This article was prepared by Robert L. Chapman.