What to Do When Medical Records Are Withheld During a Workers’ Compensation Case

When you are injured on the job, your medical information becomes legal evidence. One of the most important aspects of your workers’ compensation case is making sure that your injury is clearly and accurately documented in your medical records. Workers’ compensation exists in order to provide much-needed benefit to employees who experience injuries or diseases directly related to their work. But if your medical records, a key component of your case, are not obtained or considered, you may suffer serious consequences. This may mean that you are not able to receive the best treatment options as recommended by your doctor, or that your claim may be denied.

If the medical records relevant to your workers’ compensation claim have been withheld, it can be extremely difficult to know what steps to take next. In fact, the complexities of the legal protocol surrounding personal medical records make it nearly impossible for someone without legal training to take on the task alone. By gaining a better understanding of why medical records are so important in workers’ compensation cases, what a medical record should look like, and how to effectively and legally obtain your own medical records, you can be better equipped to partner with your lawyer in preventing any obstacles to a successful outcome of your case.

Why Medical Records Matter

As you are filing your workers’ compensation claim and working toward recovery from your injuries, your medical records may not be the first thing you think about. However, the record compiled by the doctors treating your condition is a critical component in the success of your case. Insurance companies depend on the information contained in medical reports to make decisions about injury claims. Without your medical records, there is no way to prove the cause of your injury or illness. To support your workers’ compensation claim, your medical records must be:

• Accurate and free from error
• Comprehensive and without gaps
• Directly relevant to your work-related injury or illness
• In agreement with the findings of the work accident report
• Reflective of changing medical conditions over time
• In compliance with all state and federal regulations

What a Medical Record Includes

As outlined by the Maryland Workers’ Compensation Commission’s Guide of Medical and Surgical Fees, medical records for a patient should generally include the following information:

• Patient history
• Physical exam results
• Notes that reflect patient complaints, doctor findings, plans for treatment, and updated status reports after treatment
• Copies of lab, x-ray, and other diagnostic tests
• Hospital records including operation reports, test results, consultation reports, and discharge summaries

Obtaining Medical Records

It is imperative to your case that you or your attorney request relevant medical records. These records may come from your doctor, therapist, or hospital involved in the treatment of your work-related injuries. In order to properly make a request and avoid any chance of your records being withheld, the following steps should be taken:

• Make a Written Request. Your request for medical records must be in written form to supply documented evidence of the request. Your signed and dated request letter should include your name, your physician’s name, and the name of the person who will receive your records. The federal Health Insurance Portability and Accountability Act (HIPAA) was created to protect a patient’s sensitive health information from being disclosed without their consent. Under HIPAA, you can request records for yourself, your child, or a deceased person you are legally representing. You can also authorize your lawyer to request your medical records by filling out a HIPAA release form.
• Pay Applicable Fees. Under Maryland state law, a physician is allowed to charge fees for the copy and release of medical records. A healthcare provider cannot legally refuse to release records to a patient who has unpaid medical bills. However, the hospital or physician can require the patient to pay the fees for the medical records before they are released.
• Communicate with Your Doctor. Proactively maintaining discussion between you and your healthcare provider can benefit your case in multiple ways. Informing your doctor from the outset of the work-related nature of your injury or illness will help to ensure that records and billing are handled appropriately. Additionally, you may be able to avoid the fees and inconvenience of requesting long medical report histories. By asking your doctor to give you copies of the few pages of information at the end of each visit, you can save both yourself and your doctor a good deal of extra effort.
• Ensure Records Are Relevant. Both parties in a workers’ compensation case are required to provide the opposing party with copies of all relevant medical information. However, while an insurance company is entitled to your medical records, those records must be directly pertinent to your work-related injury or illness. An insurance company may try to use unrelated records to prove that your medical condition was preexisting or a result of causes other than your work. A competent legal advocate will help protect you from a situation in which your confidential medical information is used against you.
• Seek Legal Guidance. An attorney with expertise in workers’ compensation law will understand that obtaining medical records is not always a straightforward process. Complications preventing the rightful release of your medical information can arise at any point in the proceedings. Speaking with a lawyer who is knowledgeable about the rights, requirements, restrictions, and timeframes related to medical record release can aid you in receiving the workers’ compensation benefits you deserve.

Belsky & Horowitz, LLC Can Help

Researching and understanding your rights when it comes to your medical records can be a daunting task, especially when you are recovering from a work-related injury or illness. We at Belsky & Horowitz, LLC have a long history of fighting for the rights of injured workers in Maryland. Our team has demonstrated success in advocating for our clients, skillfully handling complex disputes between employees and insurance companies. Contact us today for an obligation-free consultation to discuss your workers’ compensation case.