If you were to ask ten doctors to define the term “appropriate medical treatment,” you would likely get as many as ten different answers. Even more concerning, placing ten doctors in a room and providing them with a patient’s medical history, complaints, and symptoms will also very likely lead to ten different treatment plans and 10 different diagnoses. Similar “opinionating” frequently applies to insurance claims professionals.
For this reason, it is sometimes difficult to determine what “appropriate medical treatment” really means, even for the simplest of soft-tissue injury claims, let alone more complex injuries. However, most doctors will agree that physical therapy for soft tissue injuries extending longer than a six week period should be viewed with cautious evaluation. No one can simply look at a medical record and determine that a particular patient’s treatment has continued for more than six weeks and thus conclude that the patient has received “appropriate” medical treatment. We must look at the specific treatment received during those six weeks and for particular clues that the patient has or has not been over treated. More specifically, if the patient has the same treatment plan without any re-examination or change in the treatment plan, the records should be viewed and evaluated with skepticism.
A patient with a serious, complex soft tissue injury claim will have that injury re-evaluated by a doctor periodically and will make changes in the treatment plan in order to consistently move the patient toward a recovery stage. Treatment with continual hot packs, electro-muscle stimulation, stretching, and massage therapy for more than six weeks is not likely to be an appropriate way to deal with a complex soft tissue injury. Re-evaluation and changing the treatment plan along the way to facilitate recovery is the key.
We are often quick to label a case of “over treatment” and use the terminology “over treatment” as a means to argue for a settlement less than the medical records might otherwise indicate would be reasonable. We must also be careful not to penalize those who have lightly treated a particular soft tissue injury claim. It is very important to focus on the injury and the recovery progress made from that injury, apart from the duration of treatment received, to properly evaluate the value and integrity of the claim.
Just because the patient has treated for only two or three weeks, pursuing a home-based, outpatient regiment of physical therapy, stretching, and exercising, does not mean the injury was less severe than others who treated with a therapist for a longer period of time. In reality, the patient who was conservative with expenses should be rewarded.
The old comment within the industry “three times the medical specials” must be avoided. We must focus on the injury, the treatment plan, the recovery progress, and the period of time in which recovery can occur.
The next several articles will discuss:
- Part III: Why do some claimants over treat?
- Part IV: What is Chronic Pain Syndrome (CPS) defined and applied
- Part V: Fibromyalgia defined and applied
- Part VI: Mental Health relative to recovery
- Part VII: Other Medical Conditions that affect recovery
- Part VIII: Defending the Long Term treatment cases
- Part IX: Tactics
- Part X: Roles of the Experts
- Part XI: Questions to Ask
Author: Partners of Claims Resources and Solutions LLC publishes this article as a public service. It is provided for general information and is not intended to replace legal advice for specific cases.