What Are California Workers’ Compensation Medical Appointments and Evaluations?

How Can They Damage a Worker’s Claim of Industrial Injury?

In California Workers’ Compensation Law, Injured Workers attend both medical treatment appointments and medical legal evaluations as part of their claims. While these appointments are intended to provide either treatment or assess aspects of Injured Worker’s claim, such as permanent disability, these examinations and evaluations can also inform Insurance Companies of information that cast doubt as to the validity or the severity of both, the Injured Worker’s claim and/or their entitlement to benefits. These items are frequently called “red flags.” Many doctors who contract with insurance companies will note these “red flags” within their reporting.

During an examination or evaluation, there are many things that a doctor will do that may impact an Injured Worker’s credibility. Some of them are as follows:

Observation of the Injured Worker Beyond the Examining Room

The doctor will observe the Injured Worker going to and coming from the examining room. Frequently, a doctor will comment upon the Injured Worker’s behavior in the waiting room or in the examination room. Sometimes, they will make observations of them leaving the office and going to their car.

Utilizing Investigative Reports/Communications from Carrier/Video with Their Reporting

Prior to the exam or evaluation, a doctor can be provided investigative reports which contain damaging information such as witness statements and documents which contradict the Injured Worker’s story. Further, the insurance company or employer may contact the physician by phone call, e-mail, or letter advising the doctor to search for “red flags.” These contacts can lead to specific questioning and observations made during the Injured Worker’s appointment. The doctor can also be provided subrosa video of the Injured Worker. The videos usually show the worker either performing activities of daily living or working.

Beyond these items, there are many things that can occur or come up during these appointments and evaluations. Healthpointe, a California Workers’ Compensation Health Care Provider, published a book entitled, “A No Headache Guide to Industrial Workers’ Compensation Injuries.” Within the book, which is in part intended for physicians to review, there is a discussion concerning the “red flags”. The discussion below relates to the chapter concerning “red flags”.

What Red Flags?

Red flags are signals, signs or information that arouse suspicion concerning the validity of an Injured Workers’ claim or claim for certain benefits.

With respect to “red flags” the doctors will pay attention to the following facts concerning the injury claim:

  • There were no witnesses to the accident
  • The Injury occurred on or about a planned layoff
  • The Injury occurred on a Monday
  • The Injury was reported early in the morning
  • There was a delay in seeking medical attention
  • There is a vague mechanism of injury
  • The injured worker is not at home most of the time when phoned
  • There are many missed appointments
  • The injured worker attempts direct care
  • The injured worker is not compliant with medical care
  • The injured worker is uncooperative with physical examinations
  • The injured worker is uncooperative with attending physicians

During the physical evaluations, the doctors will make note of the following that:

  • the subjective complaints of injury far outweigh the objective findings
  • there are early widespread complaints with minor trauma
  • the symptoms continue to spread to new areas that make no anatomical sense
  • there is superficial tenderness all over the body from any palpation
  • there is widespread numbness
  • the injured worker seeks more drugs on higher levels of narcotics on a consistent basis and keeps saying the narcotics don’t work
  • the injured worker reports that that he or she will not in any circumstances return to work

The doctors will also be profiling the injured workers. Injured workers have various risk profiles based upon psychosocial issues and/or financial issues. According to the book, these profiles allegedly make injured workers vulnerable to commit fraud.

These profiles include:

  • The injured worker being a seasonal worker
  • The injured worker being unhappy with management
  • The injured worker having no health insurance
  • The injured worker having problems at home
  • The injured worker having multiple workers’ compensation claims
  • The injured worker having multiple personal injury claims
  • The injured worker having significant financial problems
  • The injured worker having dysfunctional behavior
  • The injured worker having a history of drug or alcohol abuse
  • The injured worker having a chronic illness
  • The injured worker having family members with chronic illness

In sum, when Injured Workers are being evaluated or treated, the insurance company is employing the examining or evaluating physician as a tool to discredit injured workers. It is important that an Injured Worker try to limit or minimize facts or behaviors which can raise “red flags.” Consultation with an attorney can assist with respect to presenting a Bona Fide claim.

With more than 23 years of expertise in defending workers’ rights, the Law Offices of Edward J. Singer, A Professional Law Corporation, is here to assist. If you have any questions concerning your rights, please do not hesitate to contact our offices. Please contact us today concerning any workers’ compensation questions or issues.