Disability and Medicolegal Evaluation

William G. Hughson

Many physicians dislike writing medicolegal reports. They are more comfortable with their traditional role of diagnosing and treating disease. However, providing clearly written reports is essential in ensuring that their patients receive appropriate workers’ compensation and other benefits following work-related disease and injury. These reports are read by nonmedical personnel such as disability raters, insurance claims adjusters, and workers’ compensation judges and often require the use of special forms and obscure terms to achieve specific legal and administrative goals.

It is important to distinguish between impairment and disability. Impairment describes an anatomic or functional loss caused by a disease process. Disability describes the effects of the impairment on the patient’s life, including the ability to work. It can be defined as the inability to perform at a specified level of activity, or as undue distress during the performance of that task. The degree of disability is directly related to the physical requirements of the job. For example, a teacher with a forced expiratory volume in 1 second (FEV₁) of 1 L might have no disability, whereas a general laborer would need retraining for another job. Nonmedical people who rely on the physician’s opinions make the final decision regarding disability.

The medicolegal report should contain all of the sections found in a typical medical consultation plus a detailed occupational history. A patient-generated form that is completed before an examination can facilitate the latter. The assessment section of the report should contain answers to all of the questions listed in Table 19-1. We favor a question-and-answer format because it saves time and allows a clearer explanation of the issues and the physician’s opinion. The key points that should be discussed require a very specific vocabulary with legal implications.

WHAT IS THE DIAGNOSIS?

This is generally the easiest question to answer. Each lung condition should be listed along with the evidence supporting its diagnosis. For example, the diagnosis of asbestosis is based on a history of exposure, appropriate latency, the presence of interstitial markings on the chest radiograph, pulmonary function tests showing a restrictive pattern and reduction in the diffusing capacity, and crackles on physical examination. Nonpulmonary diagnoses should also be listed, particularly those affecting impairment or disability.

IS THE DIAGNOSIS WORK-RELATED?

This requires a judgment that the disease was caused, aggravated, accelerated, or precipitated by a workplace exposure. This opinion must be expressed in terms of reasonable medical probability, which means it is more likely than not (i.e., >50% probability) that the diagnosis is work-related. The legal system understands that there will always be some uncertainty, but failure to express your opinion in terms of reasonable medical probability renders it useless for resolving the legal issues for the patient. Causation is defined as a new disease that has been caused by work (e.g., an insulator with asbestosis). Aggravation means a preexisting condition that did not interfere with work or usual activities is now worse because of employment (e.g., chronic obstructive pulmonary disease in a smoker exposed to industrial dusts). Acceleration means a preexisting condition that would naturally worsen with time deteriorated more rapidly because of employment (e.g., airway obstruction in a patient with emphysema exposed to fumes). Precipitation means a preexisting condition that became manifest for the first time because of employment (e.g., asthma in an atopic patient exposed to flour). The time sequence of the disease in relation to employment is very important. For example, pneumoconiosis takes years to develop, and immune-mediated reactions require weeks to months before sensitization occurs. It is important to note whether symptoms are worse at work, and then improve on weekends or vacations. The presence of similar problems in coworkers is highly suggestive. The nature and severity of exposure should be determined by obtaining Material Safety Data Sheets and available industrial hygiene information. The use of protective devices (e.g., respirators) and adequacy of ventilation should be described.

TABLE 19-1

Questions to Be Answered in a Disability Evaluation Report

1. What is the diagnosis?

2. Is the diagnosis work-related by causation, aggravation, acceleration, or precipitation?

3. Is there evidence of impairment? If so, how severe is the impairment? What rating system is used, and how do the patient’s findings correspond to this system?

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