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Never Give In! Disallowance Win!

Apr 19, 2021 | MAD News, NYS Workers Compensation

We got a win disallowing a right shoulder claim in a 01/18/2020 established claim for the upper back and neck. The claimant’s C-3, filed approximately 3 weeks later, listed the right shoulder as a claimed injury. The right shoulder MRI showed bursitis and a partial tear of the supraspinatus and AC degenerative joint disease. The doctor requested surgery. Our IME disputed causal relationship, stating the claimant’s complaints were really radicular from the cervical spine.

However, on cross-examination, we were able to elicit several highly damaging concessions from the treating provider, who admitted the findings on MRI could be age-related, and that they are common findings even in asymptomatic people. She admitted she could not relate findings on MRI, or the need for surgery, to the 01/18/2020 injury within a reasonable degree of medical certainty. She also admitted that reports closer in time to the date of injury are generally more accurate, that she never reviewed a 02/03/2020 report, finding no evidence of an injury to the right shoulder, and confirmed that would have been relevant in forming her opinion on causal relationship.

In defending the file, we did some research on the prevalence of partial tears and bursitis in shoulders, which helped in questioning the doctor on cross-examination. The takeaway here is to not throw in the towel even if there are positive findings on diagnostic imaging studies, and even when the claimed injury is reported relatively soon after the date of injury. Delve into what those findings mean, whether they can truly be distinguished as being related to trauma, and if those findings are prevalent in the general population. Happy Hunting!

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