Workers Compensation Law – Getting The Right Description Of Your Injury

Workers Compensation Law – Getting The Right Description Of Your Injury

If your workplace injury description is vague, or leaves something out, you will have problems getting the insurer to pay for treatment, an absolutely maddening situation resulting in delay in seeing your doctor, getting your surgery, or obtaining appropriate medication.

For example, let’s assume that you hurt your back at work, and you are one of the “lucky” few whose claim is investigated promptly and accepted as work-related. Often times you will have seen a doctor from a company list of physicians, who will conduct a brief physical exam but who will not order any expensive imaging studies such as an MRI. The doctor in good faith diagnoses you with a lumbar strain or sprain. The insurer accepts this description and includes it on the legal documents. Unbeknownst to you, and to the doctor, your injury is more serious than that, possibly a herniated disc which may require surgery. You go about your business. Six months later, you are no better, and the MRI is now ordered. It shows a herniation, and the doctor recommends surgery. The insurer denies responsibility because all it ever “accepted” was a strain or sprain.

Most people caught in this trap now have to prove that in fact the injury was misdescribed, and should be corrected – but this involves getting your doctor to testify, usually at great expense, plus delay in needed treatment, plus the possibility that the insurer will argue the herniation had some other cause.

Of course, the insurer can voluntarily amend its description to fit the now discovered facts – but it has little incentive to do, as it will mean it has to pay for much more expensive treatment than a sprain or strain would cost.

The same thing occurs when more than one part of your body is injured at work, but only one gets written down. For example, you injure both your neck and your shoulder. The initial treatment focuses only on the shoulder (neck injuries can cause shoulder symptoms). The insurer looks at one medical report, sees “shoulder” and ignores your neck. The insurer later denies treatment for the unrecorded one, even though it was part and parcel of what happened.

I should add that the insurer has a legal obligation, often ignored, to accept or reject responsibility for your injury within 21 days of the date it knows about it. It may not have complete information within that time – for that matter, you may not either. You may not have had time to be fully evaluated, the doctor may be waiting for a test, or the diagnosis simply may not be known yet. But the result is the same: a later denial of payment for necessary medical treatment.

For these reasons, what you thought was a settled issue becomes, to your dismay, another conflict, one in which the insurer has a legal, but not necessarily a factual, excuse to deny your bills, while you try to prove the existence of the true extent of your injury.