LIABILITY CLAIMS AND THE PAYMENT OF MEDICAL EXPENSES

            Liability is the source of last resort for the payment of medical expenses and yet it may be the most important source for the payment of these bills. The liability damages award is a source for medical expense payment in the following areas:

In liability cases, as with PIP and Worker’s Compensation, the expenses must be reasonable and related to the injury caused by the accident or incident. In such cases the patient (plaintiff) must prove “negligence” on the part of the defendant. That is, the plaintiff must prove that the defended violated a duty of care owed to the plaintiff, and that the violation (such as careless driving) proximately caused the plaintiff’s injury.

The concept of proximate cause is simply that the injuries which have been suffered by the plaintiff were not only caused by some action of the defendant, but also the injuries were a foreseeable result of such action with no superseding cause being present. In other words, the injury must be caused by the defendant’s act and not be some other unforeseeable unrelated event.

Medical documentation is crucial to establish both the severity and the causation of the injury. Medical records, and ultimately, medical testimony regarding such areas as the history, objective documentation, subjective complaints, diagnosis, prognosis and prescriptions are vital to successfully presenting a plaintiff’s claim for both pain and suffering and for the recovery of medical expenses.

If the medical documentation is not clear, concise, and yet, thorough, an otherwise compensable claim can fail on any one of these counts:

One term that becomes very important is “within reasonable medical probability”. This simply means that a medical conclusion is more likely than not be true. Another way to view it is that there is better than a 50% chance that the conclusion is correct (even a 51% chance that an event occurred or will occur is within reasonable probability). The key term is probability. This is more than a possibility, but does not require certainty or the absence of any other explanation. If the cause of a particular injury is more likely than not (i.e. Probably, or better than 50% chance) to have been caused by one event as opposed to another, it is so, within “reasonable medical probability”. Relatedly, do not be confused by the term “reasonable medical certainty”, as this term means the same thing.