Injury, Illness and Work-Related Activity


The Crucial Role of Causation Letters in Workers’ Compensation Claims

INTRODUCTION

In workers’ compensation, the ability to establish a clear connection between an injury or illness and the workplace is fundamental to the success of a claim. Causation letters serve as the vital link that connects medical evidence to legal standards, ensuring that the injury is recognized as work-related. This white paper delves into the essential role that causation letters play in substantiating claims, thereby supporting informed and equitable decisions.

According to the National Council on Compensation Insurance (NCCI), disputes over causation are a leading reason for denied claims, with approximately 25% of denied workers’ compensation claims involving issues related to causation [1].

man signing paperwork with arm cast

PROBLEM STATEMENT

Causation refers to the underlying cause of an injury or loss. When workplace injuries or illnesses occur, they can have profound effects on employees’ lives and financial stability. Navigating the complexities of the workers’ compensation system, particularly in proving that an injury is directly linked to the workplace, can be challenging.

A common issue arises when causation is not firmly established or is questioned early in the claim process. Furthermore, medical records must be thoroughly reviewed to ensure that all treatments and diagnoses are directly related to the established work-related injury. For example, while an initial diagnosis of “low back pain” could become a two-level fusion with established causation, how could subsequent complaints of knee pain also be related to the original injury?

Statistics reveal that 70% of workers’ compensation claims involve musculoskeletal injuries, with back injuries being the most prevalent [4]. These types of injuries frequently lead to disputes over causation, especially when pre-existing conditions are present or when the symptoms of the injury evolve over time.

CORRELATION VS. CAUSATION

It is crucial to distinguish between correlation and causation in workers’ compensation claims. An injured worker may develop other medical issues during the treatment of a work-related injury, but this does not necessarily mean the initial injury caused these additional issues. For instance, just because a rooster crows before sunrise does not mean the rooster causes the sun to rise—correlation does not imply causation.

Properly separating treatment for work-related injuries from treatment for pre-existing or non-work-related conditions is essential. This distinction allows injured workers to control their care and select appropriate

specialists for non-industrial conditions. For example, it would be inappropriate for an orthopedic surgeon to manage a patient’s hypertension. However, if elevated blood pressure is incorrectly linked to a work injury, it may lead to treatment beyond the scope of the injury and recovery from that injury.

By clearly delineating work-related treatments, employers and their representatives can confidently review and approve treatment recommendations, ensuring that the care provided is both causally related to the injury and grounded in evidence-based medicine. Studies indicate that the misclassification of work-related injuries can lead to inappropriate treatment and increased costs, with misclassified injuries costing 33% more to treat on average [3].

 

health checklist sheet with anatomy drawings

CAUSATION LETTERS: THE VITAL LINK

Causation letters are the crucial documents that establish a direct connection between an employee’s injury and the work-related activities or events that caused it. These letters not only advocate for the employee but also fulfill legal and insurance requirements by providing a detailed account of how the work-related event led to the injury. Either the employer or the employee (often through legal counsel) may request a causation letter.

To ensure that a causation letter is both accurate and fair, the physician must have a comprehensive understanding of the injured worker’s complete medical history and job duties. To assist the physician in this process, the following information should be provided:

 

MEDICAL HISTORY

• Occupational Injury Documentation: This includes all relevant medical records, such as emergency department reports, hospital records, imaging studies, and occupational medicine clinic records. Any previous records related to the injury should also be provided to the current treating physician to ensure a complete understanding of the injury’s mechanism and its sequelae.

• Pre-Injury Medical History: It’s essential to include the injured worker’s medical history before the injury, not only for determining compensability but also for ensuring patient safety. This includes information on previous and current health conditions, surgeries, and co-morbidities that may influence treatment decisions. For example, a review may reveal that the injured worker had prior treatment for knee or lower back pain, indicating a pre-existing condition that may need to be managed under the claim to restore the injured worker to the pre-injury status.

 

JOB INSIGHTS: PAYERS CAN PROVIDE CLARITY ON THE WORKER’S JOB DUTIES BY:

• Inviting the physician to the worksite to observe the tasks involved.

• Videotaping the job being performed allows the physician to see the actual work tasks.

• Providing a thorough and detailed job description to help the doctor understand the daily activities of the worker.

 

REVIEW OF PREVIOUS CLAIMS AND EMPLOYMENT HISTORY:

The claims adjuster should examine the worker’s previous claims and employment history to identify any activities or conditions that might be consistent with the current complaint. Additionally, determining the worker’s employment start date can help identify potential red flags, such as whether the worker is a long-time employee or a new hire, which might indicate a pre-existing condition.

 

doctor looking at x-rays

INCORPORATING EVIDENCE-BASED MEDICINE

To ensure that treatment recommendations are in line with recognized standards, causation letters should reference the Official Disability Guidelines (ODG) or other approved standards. ODG provides evidence-based guidelines for managing a wide range of conditions commonly seen in workers’ compensation cases. For instance, when dealing with musculoskeletal injuries, ODG can help determine the appropriate duration of treatment, expected recovery times, and when to consider alternative treatments if progress stalls.

Referencing ODG in a causation letter not only strengthens the document’s credibility but also aligns the recommended treatment with best practices in the industry. For example, if a causation letter supports ongoing physical therapy for a back injury, citing ODG guidelines can validate that the recommended duration and type of therapy are consistent with evidence-based practices. This approach can be particularly useful in defending the necessity of certain treatments if the insurer or employer challenges them [6].

 

man and woman looking at paperwork together

STRUCTURE OF A CAUSATION LETTER

A WELL-CRAFTED CAUSATION LETTER TYPICALLY INCLUDES THE FOLLOWING ELEMENTS:

• Introduction: Briefly states the purpose of the letter and identifies the author (usually a medical professional).

• Employee Information: Details the injured worker’s name, job title, and employment details.

• Incident Description: Provides a detailed account of the workplace incident or conditions leading to the injury.

• Medical Evaluation: Includes a thorough medical examination report, highlighting the nature and extent of the injury.

• Causal Link: Clearly explains the medical opinion on how the injury is related to the workplace incident or conditions, supported by evidence and reasoning.

• Conclusion: Summarizes the findings and reinforces the causation statement.

• Signature and Credentials: The letter should be signed by the medical professional or expert, including their credentials and contact information.

 

BEST PRACTICES FOR WRITING CAUSATION LETTERS

• Accuracy and Detail: Ensure that the sequence of events is logically traceable and provides a strong connection between the work incident and the injury.

• Professional Tone: Use clear, understandable language that explains the injury or condition in both medical and lay terms. Avoid assuming the reader has medical knowledge.

• Evidence-Based: Support your diagnosis and treatment recommendations with medical evidence, including ODG, where applicable [6]. Consider how pre-existing conditions may influence your analysis.

• Clarity: Clearly state what supports your conclusion and ensure that your reasoning is easy to follow.

 

CASE STUDY: SCENARIO 1

overweight man holding back with pain

A 45-year-old worker files a claim for a lumbar strain allegedly sustained at work while lifting from floor to waist height. The worker is overweight, has been taking NSAIDs for low back pain from a reported injury with a previous employer. He has also been attempting to switch from the second shift for four months, according to his supervisor.

Medical records indicate he previously rated his low back pain as 4/10 while taking medication. After the reported incident, his pain increased to 6/10. Radiographs show lumbar degenerative disc disease. The occupational medicine provider considers this an exacerbation of a pre-existing condition and treats it with a Medrol dose pack and physical therapy. Four weeks later, the worker states his pain is back to 4/10, and he cannot return to his previous job due to pain allegedly caused by the work injury.

The injured worker could be declared at pre-injury status if his pain is back to its previous level. However, he sees a spine specialist on his own who recommends a discectomy at L4-L5. The injured worker thinks his current employer is responsible for this treatment recommendation. Now, the opinion of the spine specialist needs to be addressed. The injured worker is sent for an independent medical evaluation. The physician is asked to write a causation letter to determine whether the need for surgery is related to the reported lifting incident.

In this scenario, referencing ODG could help justify the decision to pursue conservative treatment before surgery. The ODG guidelines may suggest a standard course of physical therapy or medication management before considering surgical intervention, providing a solid basis for the treatment plan and the timeline proposed [6].

 

CASE STUDY: SCENARIO 2

middle aged woman holding wrist with pain

An overweight 58-year-old woman claims carpal tunnel syndrome (CTS) in her right wrist, undergoes surgery, and returns to work. Six months later, she reports that her wrist never fully healed and files a claim for CTS in her left wrist, alleging both were caused by repetitive motions at work.

Comorbid factors such as age, obesity, and gender are clear contributors. While CTS can be work-related when there is a combination of force and repetitive motion or awkward posturing, repetitive motion alone is not an evidence-based cause of CTS [5]. Given that the first surgery was compensable, the worker might expect the second surgery to be covered as well. However, a different adjuster reviews the claim and questions causation before surgery is presented as the only option. While the injured worker is performing the recommended conservative treatment, the provider is asked to consider the current and past medical history. A video of someone performing the same job might also be shown to the physician to provide clarity on the worker’s repetitive motion, if any. When non-work-related risk factors outweigh work-related causes, the employer may not be responsible for compensability.

 

CONCLUSION

Causation letters are the crucial link between work and injury in workers’ compensation claims. These letters help clarify the relationship between an injury and the workplace, providing essential evidence for fair and informed decisions. However, asking a provider to address causation involves some risk. By ensuring that physicians have all relevant facts—such as the injury details, medical history, job duties, and relevant guidelines like ODG— employers can confidently fulfill their obligations to injured workers. Accurate, clear, and evidence-based causation letters are vital in navigating the complexities of workers’ compensation claims, particularly in cases where causation is often in question.

 

REFERENCES:

[1] National Council on Compensation Insurance (NCCI). “Workers’ Compensation Claim Frequency and Severity.” 2023.

[2] Smith, Jane, et al. “The Impact of Causation in Workers’ Compensation Claims.” Journal of Occupational Health, vol. 45, no. 3, 2022, pp. 123-134.

[3] American Journal of Industrial Medicine. “Misclassification of Work-Related Injuries.” 2022.

[4] Bureau of Labor Statistics (BLS). “Musculoskeletal Disorders: Impact on Workers’ Compensation.” 2021.

[5] National Institute for Occupational Safety and Health (NIOSH). “Evidence-Based Guidelines for Carpal Tunnel Syndrome.” 2022.

[6] Official Disability Guidelines (ODG). “Treatment in Workers’ Compensation.” 2023.

 

ADDITIONAL RESOURCES:

This white paper was prepared by Carlisle Medical in collaboration with Louise Moore, RN. She is a Case Manager Director and has 27 years of experience in the industry. Our company assists insurance carriers, third- party administrators and employers to significantly reduce their workers’ compensation costs. Our experienced staff of licensed pharmacists and nurses can assist companies with injuries ranging from minor to catastrophic.

**The information, including but not limited to, text, graphics, images and other material contained in this white paper are for informational purposes only. No material in this white paper is intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment and before undertaking a new healthcare regimen, and never disregard professional medical advice or delay in seeking it because of something you have read in this document.