Tips for Writing a Workers’ Comp Causation Letter

Physicians are sometimes asked to provide “causation letters” for injured workers seeking workers’ compensation benefits for a diagnosis of injury or illness. A causation letter is an original medical narrative report that explains the cause of injury or illness (or lack thereof) in a workers’ comp case.

To be covered under a workers’ compensation claim, the injured worker must prove the diagnosis in question resulted from a work incident or accident. Texas has a “substantial factor” requirement in workers’ compensation cases. The medical evidence must show the work incident or accident was a substantial factor in bringing about the injury, without which the injury would not have occurred.

A thorough causation report addresses the sequence of events that provide a strong, logically traceable connection between how the injury occurred and the conditions to establish causation, if applicable.

The Texas Department of Insurance (TDI) offers these guidelines for writing a causation report:

• Don’t assume the reader has any medical knowledge. Define and thoroughly explain the injury or conditions in question; describe how the injury or condition typically occurs. Just listing the diagnosis or codes is not sufficient.
• Explain what objective findings led you to believe the employee does or does not have the injury.
• Explain what happened: Explain the accident/incident and why these forces, if applicable, could result in the claimed injury or condition, or an aggravation of a pre-existing injury or condition.
• Be as specific as possible as to details and where you found them, e.g., specific medical records, patient’s account, carrier’s analysis.
• Objectively recount any contradictions you find regarding the accident/incident.
• Identify preexisting conditions, prior surgeries at the time of the accident/incident, and symptom onset, and explain how these affect your analysis.
• If applicable, explain how the accident or incident was a substantial factor in causing the injury or illness in question. Also explain how, without the accident or incident, the injury or illness in question would not have occurred.
• Use and cite evidence-based medicine, when appropriate.
• Explain what supports your conclusion that the injury or illness was or was not the result of this accident or incident.

(Derived from TDI’s Summary of Best Practices: Steps to a Non-Conclusory Causation Explanation and Extent of Injury presentation)

Visit TMA’s Workers’ Compensation Resource Center for more tips and information.

TMA Practice E-Tips main page