Causality

Causality

The independent medical examiner is expected to address causality unless it has already been accepted by the insurer, is presumptive (ie, automatically accepted based on case law or legislation), or has been established through litigation. Causality always must be addressed when the referral source has significant doubts regarding the legitimacy of a claimant’s complaints as related to the initial injury (or alleged injury). Even in the presence of a clear causal relationship between an accident and subsequent physical pathology, one may need to state whether an exacerbation, recurrence, or aggravation of a prior condition occurred and apportion liability accordingly.

               

When examining a claimant who seems credible and insists that one or several medical problems were caused by a given event or exposure, many physicians accept this as fact, even though a careful analysis of the situation would clearly indicate otherwise. The independent examiner is hired to evaluate the claimant objectively, and is expected to base determinations of causality upon commonly accepted physiologic, epidemiologic, and statistical principles, rather than make decisions empirically or based solely on the claimant’s history and the apparent believability thereof. Multiple definitions of causation and their application are discussed in the AMA Guides fifth, and in greater detail in the Guides companion, Master the Guides Fifth.