The role of medical records in workers’ compensation claims

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Despite all safety measures that a business has in place, employees may still get into workplace accidents or suffer from work-related illnesses. When these situations occur, injured or sick employees (or their beneficiaries) in the United States can file for a workers’ compensation claim to secure the following benefits:

  • Medical care coverage
  • Income replacement payments for lost wages, if the employee’s recovery takes a long time
  • Coverage for new job role training, if the employee can’t return to their old job role
  • Long-term disability benefits, if the employee can no longer return to work
  • Payment for funeral expenses, if the employee dies

By having the financial means to receive healthcare treatment, injured or ill employees can hope to recover more quickly and thus get back to work faster.

Unfortunately, insurers could unjustly deny claims or come up with excuses to greatly reduce payouts. As a workers’ compensation lawyer, retrieving your client’s medical records is a good start to defending your client’s rights to insurance benefits.

Related article: The importance of medical records for insurance companies

What is the importance of medical records in a workers’ compensation claim?

Before accepting or denying any workers’ compensation claim, insurance companies review all the evidence available to them. If there are discrepancies between the report your client filed at work and the medical records they submitted, the insurer will suspect the claim to be fraudulent.

Moreover, if your client was rushed to the emergency room (ER) after a work-related accident and ER records show illegal drugs in your client’s system, then the insurer may deny the claim.

Medical records also serve as the basis for determining if a particular procedure or treatment is medically necessary and, therefore, covered by the workers’ compensation insurance.

Records of your client’s medical history are also important because these show if your client has pre-existing health conditions. In most US states, workers’ compensation insurance only covers the worsening of an employee’s physical condition caused by the work-related injury or illness, not those caused by pre-existing conditions.

If a claimant’s pre-existing condition is medically related to their claim, then the benefit they’ll receive will likely be affected. For example, if your client has a history of knee arthritis and they suffered a knee injury at work, their compensation claim could be reduced or denied. This is because pre-existing health conditions could contribute to or exacerbate work-related injuries or illnesses. Pre-existing conditions could also compromise or prolong recovery. In such instances, the insurer may not cover some treatment costs.

It’s not hard to see why some people would rather not state that they have pre-existing conditions in their insurance applications, but doing so is ill-advised. This is because if, during the claims review, it was discovered that your client didn’t disclose their history of knee arthritis, your client’s physician may no longer consider your client as trustworthy. They may even withdraw their support for the claim.

How can lawyers easily obtain their client’s medical records?

Insufficient medical documentation is the top reason why workers’ compensation claims are denied or delayed. This is why you should make sure that you have your client’s medical chart. The problem is that obtaining all medical paperwork relevant to the claim can be difficult and time-consuming. Fortunately, you can seek the help of Record Retrieval Solutions (RRS).

With us as your partner, you simply have to submit your request for medical records via our online portal. You can also track the status of your order on the portal. After 12 days on average, you can download your requested records through the same portal.

Ready to get started? Get in touch with us today!

About The Author

img Chuck Dart
Chuck Dart started in the record retrieval business three decades ago. As the industry evolved from analog to digital, he recognized an opportunity to create a single, simple online solution that standardizes the record request and retrieval process across the entire healthcare industry.