Extent of Injury Disputes in Workers Compensation Cases

Prior to your work-related injury, you were working full-time, without restrictions, and had an active personal life with your family and friends. However, the insurance carrier has told you that your current pain and injury are preexisting conditions or an ordinary disease life.
Despite your treating doctor, the specialist, and medical testing clearly indicating that you sustained a severe work-related injury the insurance is limiting your work-related injury to a simple sprain, strain or contusion.
If any of this sounds familiar, you may have an extent of injury dispute. The question to be resolved in an extent of injury issue is whether the claimed condition is causally related to or is a part of the compensable injury. For example:
The injured worker sustained a compensable injury to his back. He underwent various diagnostic tests in the treatment of his compensable injury including a myelogram, and a lumbar and abdominal CT scan, which the insurance carrier approved. Upon successful surgical treatment of the 2 ruptured discs, the insurance denied paying the medical providers, post-operative rehabilitation, and prescriptions. The medical records reflect that the injured worker was examined by five doctors. Each of these doctors diagnosed 2 ruptured discs resulting this work-related. Even though the insurance carrier approved the surgery, any treatment beyond a lumbar sprain/strain was denied. A review of the Insurance Carrier’s records clearly indicated the nature of the injury was sprain/strain, and it was only accepting a lumbar sprain/strain for the compensable injury.
Unfortunately, injured workers and doctors are unaware that Texas Workers Compensation Rules allows for an insurance carrier to raise an extent of injury issue at any time; an insurance carrier is only responsible for the compensable (accepted) injury; and preauthorization/approval of medical treatment is not a guarantee of payment.

Even though this action by the insurance carrier prevents a claimant from returning work, it saves the insurance carrier a lot of money:

1. The insurance carrier is not responsible for paying for any medical treatment beyond the compensable/accepted injury.
2. Due to an extent of injury dispute, a medical provider will not move forward with anymore treatment because the medical provider will not be paid.
3. Typically, sprain, strains, or contusion do not require long-term treatment, prescribed drugs, surgery, or referral to specialist or MRI.
4. The insurance carrier can now suspend an injured worker’s weekly benefits because the reason for not working is due to extent of injury, not the compensable injury.

When extent of injury is not addressed immediately, the claimant will often have to go without money and medical benefits for some time while the extent of injury is being litigated. Furthermore, the longer the condition goes untreated, the greater potential there is for additional damage or permanent impairment.

Causation and extent of injury go hand in hand. Every extent of injury dispute requires a finding about the cause of the diagnosis in dispute. More and more, insurance carriers are accepting liability for less severe diagnoses, like sprains and strains, and disputing serious diagnoses like herniated discs or carpal tunnel syndrome. A proper diagnosis with a medical opinion about the cause of the condition will give the claimant the best chance to prevail.

Medical opinions about the cause of an injury must be detailed. The mechanism of injury must be clearly understood and spelled out in the report. If the actual events and the medical report’s recitation of the events are different, then the doctor’s opinion is of no use. If the report has nothing more than a statement that the diagnosed condition is related to the work incident, it is considered to be “conclusory” and is of no use. There must be a detailed explanation about why the doctor believes, within a reasonable medical probability, that the work incident caused the diagnosis in question.

The other type of extent of injury case is where the whole body part has been denied. For instance, the carrier has accepted liability for a low back injury, but has denied liability for a neck injury. These cases still require diagnosis and an opinion about causation, but many judges will look at the initial complaints for guidance.

In these types of cases, the first question most often asked by a judge is, “when the neck injury was first documented in the medical records?” Problems usually arise because the claimant treated at the emergency room, where the focus was on the primary complaint and not the secondary complaints, or a company doctor where not all of the complaints are documented. When judges are concerned about the initial complaints, or the time between the event and the first complaint, documentation becomes vital.

With detailed documentation and thoughtful analysis of how injuries result from reported events, injured workers will prevail on liability issues. This may require medical providers to give even more than they already do, but the rewards should include happy patients who refer new patients and medical bills that have to be paid after liability has been established.

A medical provider that provides a consistent history of cause of that injury can minimize disputes. Also, medical providers that maintain detailed daily medical documents, often have fewer preauthorization disputes. A detailed history of medical treatment is essential if the injured worker wants continued medical treatment necessary for his or her recovery. Furthermore, detailed medical documents will also assist an administrative judge/hearing officer if the claim proceeds to benefits contested case hearing (BCCH) or medical contested case hearing (MCCH)
In extent of injury claims, the first question most often asked by an administrative judge is, when was the disputed condition or body part first documented in the medical records? Problems usually arise because the claimant treated at the emergency room, where the focus was on the primary complaint and not the secondary complaints, or a company doctor where not all of the complaints are documented. There has been Appeal Panel Care were the “company doctor” failed to mention the neck complaints in any records. However, there were films documenting that x-rays of the neck were obtained on the initial visit.
A workers’ compensation attorney will address an extent of injury disputes as early as possible. It is usually easier to address diagnosis and causation early in the claim, as opposed to later in a claim. Furthermore, Insurance Carriers typically start denying medical treatment within 60-days by limiting the injury to simple like sprains and strains, even though the diagnosis is more severe. Remember, the longer the injury and/or condition goes untreated, there is greater potential for additional damage or permanent harm to the injured worker’s physical structure.

Bill Abbott

Bill Abbott

WILLIAM (BILL) C. ABBOTT was born in Dallas, Texas. He was admitted to Texas State Bar 1998, and in U.S. District Court, Eastern and Southern Districts of Texas in 2002. He graduated from University of Texas (B.A.) in 1995 and Texas Tech University (J.D.) in 1998. He is a member of Houston and American Bar Associations and Texas State Bar Workers’ Compensation Section.
Bill Abbott