For Qualified Medical Evaluators, typically the initial introduction to the facts of a claim comes in the form of a cover letter sent from the applicant’s attorney, the defense attorney, or the claims adjuster. In addition to the claim numbers, dates of injury, and scheduling information for the evaluation, these letters often contain a list of questions, requests, and explanations to provide context the attorney believes may support their position. As an unbiased, independent participant in the process, it may feel like you are reading something you shouldn’t, like it’s an attempt to influence your opinion before the evaluation begins. The reality is, if the letter has been prepared and served in accordance with the applicable regulations, reviewing it is not just appropriate, but expected.
The key to approaching a cover letter is to distinguish the attorney’s advocacy for their client from the evidence itself. Consider the content in terms of the issues being raised and not the conclusions or assumptions that may be implied within the text. The letter certainly should not be ignored, but it also should not be treated as a set of instructions. Understanding what an attorney is trying to accomplish can actually help you conduct a more focused evaluation.
For example, an attorney might ask:
“Please address whether the applicant’s current condition is consistent with the mechanism of injury described in the history.”
This may appear to be a standard, templated inclusion, but it could also indicate to you that causation is an important issue in the case. If this is the applicant’s attorney, they may believe the mechanism strongly supports an industrial injury, while the defense may argue that the condition is more degenerative or unrelated to the claimed event. Similarly, if this letter comes from the defense, they may be emphasizing the possibility of nonindustrial causation.
Regardless of the attorney’s intent, you are still required to independently determine whether the mechanism is medically consistent with the claimed condition. The attorney has identified an issue for you to evaluate; they have not determined the answer. At times, though, intent can be relevant, particularly when a question contains an assumption.
An attorney might write:
“Because the applicant had no prior symptoms, please explain how the industrial injury caused the applicant’s current condition.”
In this case, the absence of prior symptoms would be important, but the letter itself is not evidence that they do not exist. Rather than relying on that statement, a QME should consider their own examination and the medical records. Even when an attorney presents a statement as fact, the prior treatment records, imaging, complaints, or other evidence may tell a different story.
Again, this approach applies to both sides. It would be unfair to assume that one attorney has more of an agenda than the other. Either can provide information that helps you identify an important issue, and either can make statements that obscure or complicate the purpose of the evaluation. Neither side should influence your opinions or conclusions. Always consider the question, but also independently evaluate the premise.
With that in mind, the best approach is to view the cover letter as a roadmap rather than a set of instructions. It can tell you what the attorneys believe is important, where they believe the disputes lie, and which questions they want addressed. Understanding the attorney’s perspective can make your evaluation more focused and complete, but it is critical that you approach it in a manner that preserves the independence and objectivity essential to your role as a QME.