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)
Want to learn more about the Texas workers’ comp system? Attend the 2017 Texas Workers’ Compensation Education Conference in Georgetown from Sept. 11 to 12 or Dallas/Richardson from Oct. 12 to 13, where you can attend breakout sessions specific to physicians. Register and make your discounted hotel reservations now.
Visit TMA’s Workers’ Compensation Resource Center for more tips and information.
Published Aug. 11, 2017
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Last Updated On
August 14, 2017