Scrutinizing Claims of Work-Relatedness in Workers' Comp

Workers’ compensation was created to address health problems specifically of a work-related nature. Unfortunately, discrepancies have emerged between that purpose and the reality of modern workers’ compensation. As has been explained in the American Medical Association’s text, Guides to the Evaluation of Disease and Injury Causation (referred to as AMA Causation for the remainder of this article), there are many clinical issues that find their way into workers’ compensation despite little to no scientific support for claiming that those issues are work-related. Examples specified in AMA Causation include carpal tunnel syndrome, complex regional pain syndrome type 1, post-traumatic stress disorder, and chronic back pain. Conversely, AMA Causation also explains that the potential work-relatedness of some conditions may go unrecognized because of the less than obvious nature of the relevant occupational risks.

One factor in the development of such discrepancies is the dominant tendency for workers’ compensation systems to allow doctors to offer opinions, rather than facts, regarding work-relatedness. Reviews of workers’ compensation files (such as a review of files that was undertaken specifically in conjunction with the creation of AMA Causation), reveal that doctors develop opinions regarding work-relatedness in an idiosyncratic, haphazard, and even cavalier fashion. Similarly, a Florida workers’ compensation insurer surveyed its panel of doctors about how they determine work-relatedness, and the prevailing response was that they do not — they simply assume work-relatedness based on the fact that the patient came to see them in the context of a workers’ compensation claim. Based on such reviews and reports, one might develop the impression that there are no health-care standards for evaluating work-relatedness.

AMA Guide Can Help AMA Causation was published in 2008 with the goal of eliminating such impressions. It specified scientific and clinical standards for determination of work-relatedness. Given the information in this text, workers’ compensation professionals can scrutinize conclusions regarding work-relatedness from any individual case and determine whether the doctors who offered the conclusions did so in a manner that is factually based, scientifically credible, and consistent with professional standards.