Medical evidence is relied upon for determinations of liability (absent valid factual or legal defenses), value of indemnity benefits, and the necessary course of care. However, only substantial medical evidence may be relied upon in good faith.
What is substantial medical evidence?
A medical opinion is substantial evidence when it is based on reasonable medical probability, relevant facts, and follows an adequate examination. Furthermore, the reasoning of the opinion must be free of speculation or surmise and clearly set forth.
What are the best practices to secure substantial medical evidence?
Effective communication and round table discussions
Once the file materials are sent to counsel, they must be thoroughly analyzed. Any gaps in information or potential discovery must be borne out. In most instances, absent an opportunity for settlement, substantial medical evidence and discovery will be needed. It is imperative that counsel and client reach an accord on the discovery plan of action.
When the complexity of the matter calls for a deeper discussion with additional members of the claims or carrier team, a round table discussion with all necessary parties is a highly effective means to hammer out prospective issues.
Thereafter, open dialogue must be maintained regarding the status of the discovery.
Expeditious Discovery
To produce substantial medical evidence, the examiner must have a clear picture of the applicant’s past medical history and facts relevant in the present claim. This is best handled through the production of sworn deposition testimony, medical reports, and subpoenaed records.
Proactive counsel will be able to schedule depositions and issue subpoenas for relevant records in quick succession. Conversely, when one is reactionary, the claim will drag out, bloat with cost, and worsen over time. Aggressive opposing counsel will seize on the delayed action with litigation of minor issues to force capitulation and a shift of focus.
Accordingly, to keep focus and the claim moving forward, once discovery is received, it must quickly be analyzed for its potential use and impact on the matter. The discovery should then be sent to the evaluator with a detailed position statement to ensure the best chance for issuance of a comprehensive report.
Thorough review of the medical opinion’s substance
Once a medical opinion is issued, it must be reviewed for its qualification as substantial medical evidence. This is time sensitive as a failure to act may result in a party’s waiver of objections.
If the examiner’s opinion requires clarification, an interrogatory or deposition should be considered. Counsel proceeding to a deposition must adequately prepare to clarify the issues noted but also to rehabilitate the witness; if necessary, following opposing counsel’s questions.
Conclusion
The defense of workers’ compensation claims necessitates the use of substantial medical evidence. As a claim progresses, the parties may be presented with challenges; however, substantial medical evidence can be secured with effective communication, expeditious discovery, and prompt analysis of medical opinions. At Karbassyoon Law, we work hard to ensure that claims move forward smoothly and substantial medical evidence is used effectively to secure the best possible outcome for our clients.
This post provides a brief overview of best practices to secure substantial medical evidence in defending workers’ compensation claims. Each claim is different and therefore, due consideration should be given to the specific facts. For more information and a detailed review of your case, contact Naveed Karbassyoon at: NaveedK@KarbassyoonLaw.com or by telephone at: (949) 617-1757.