In a personal injury case in Massachusetts, medical documentation is one of the most important pieces of evidence. It’s the foundation of your case that provides clear proof of your injuries, treatments received, and the impact on your daily life. Without strong medical documentation, insurance companies and defense attorneys may argue that your injuries weren’t severe or question whether they were caused by the accident.
So, if you’ve been injured due to someone else’s negligence, you must get prompt medical attention and keep track of all related medical records. This way, you have a clear trail that documents your injuries and how they’ve affected you in case you want to pursue legal action.
Why Medical Documentation is Integral to a Personal Injury Case
Having thorough, detailed, and accurate medical documentation is huge in personal injury cases. Here’s why:
1. Proving the Existence and Severity of Injuries (H3)
Medical records serve as objective evidence of your injuries, confirming that you sought treatment and received a professional diagnosis. Without these records, an insurance adjuster or defense attorney may argue that your injuries are exaggerated or did not occur as a result of an accident.
For example, let’s say Keith suffered from whiplash after a car accident. He decided not to get medical care, thinking that healthcare providers couldn’t do anything for him. Because of this, the insurance company downplayed the severity of his claim, using the lack of documentation to argue that his injuries weren’t severe.
Had Keith gone to the emergency room and been seen for his injuries immediately, he would have had a diagnosis from his physician stating that he suffered whiplash due to his accident. This would have strengthened his claim.
2. Establishing a Clear Link Between the Accident and the Injuries (H3)
One of the most common defenses used by insurance companies and defense attorneys is the argument that the injuries were pre-existing or caused by something other than the accident. Medical documentation helps establish a direct connection between the incident and your injuries.
In Massachusetts, causation is a core element in personal injury cases. This means that you must prove that the defendant’s negligence directly caused your injuries. Thorough medical records starting on the day of the accident that document your symptoms strengthen your case and provide clear evidence that the injuries were related to the accident.
3. Demonstrating the Long-Term Impact of the Injuries (H3)
Some injuries have long-lasting effects that may affect your ability to work, engage in daily activities, or enjoy life as you once did. For example, a traumatic brain injury (TBI) or spinal cord injury may have permanent and life-altering consequences.
Medical documentation of whatever care you need after the incident, such as ongoing treatment records, physical therapy reports, and specialist evaluations, helps demonstrate the long-term impact of your injuries. This is often a must-have in securing compensation for future medical expenses, lost earning capacity, and pain and suffering.
4. Strengthening Your Case in Settlement Negotiations (H3)
Insurance companies often attempt to minimize the amount they have to pay by arguing that your injuries are minor or that your medical treatment was unnecessary. Detailed and consistent medical records provide indisputable proof that your medical care was required.
When negotiating settlement offers, your attorney will rely on medical records and receipts to calculate the full extent of your damages, including:
- Past and future medical expenses
- Lost wages and diminished earning capacity
- Pain and suffering
- Emotional distress
When you have a well-documented medical history, your likelihood of receiving fair compensation without having to go to trial increases.
5. Supporting Your Case in Court (H3)
If you don’t receive a fair settlement offer and your case goes to trial, medical documentation becomes even more important. Doctors, surgeons, and medical professionals may be called in as fact/treating witnesses or expert witnesses to testify about the extent of your injuries, the treatment required, and the long-term prognosis.
Massachusetts law allows certified medical records and bills to be introduced as evidence in personal injury cases, which allows you to present your medical history without requiring healthcare providers to appear in court. However, in order to be effective and admissible, the records must be accurate, thorough, and properly obtained.
How to Get Your Medical Records for a Personal Injury Claim in Massachusetts
Under the Health Insurance Portability and Accountability Act (HIPAA), you have the right to request copies of your medical records. This process can be somewhat complex but generally goes like this:
- Figure out what records you need: First, determine what records you need. This varies based on the type of care you needed and received but may include emergency room reports, doctor’s notes and diagnoses, X-rays, MRIs, and CT scans.
- Request your records: Ask your healthcare provider for their medical records release form or, if they don’t have one, what you need to do to get a copy of your medical records. Generally, you need to provide a written request or complete the necessary forms.
- Be aware of fees and processing times: In Massachusetts, healthcare providers can charge a reasonable fee for copying medical records, so be prepared to pay it. Additionally, be aware that it may take up to 30 days to receive a response. If you don’t hear back within this timeframe, you may need to follow up or seek legal assistance.
- Ensure your records are complete and accurate: Once you receive your records, review them to ensure they include all necessary documentation, aren’t missing any pages, have correct entries, and accurately reflect your diagnosis and treatment. If you find discrepancies or missing information, request corrections from your healthcare provider.
Common Mistakes to Avoid in Medical Documentation
Given the importance of medical documentation in personal injury cases, it’s important that you handle them carefully and avoid these common mistakes:
- Delaying medical treatment: Waiting too long to seek medical care can potentially weaken your claim. Insurance companies and defense attorneys may argue that your injuries weren’t serious or were caused by something else.
- Failing to follow doctor’s orders: Follow all of your doctor’s orders. Skipping treatments, ignoring recommendations, or stopping seeing your doctor may lead the other party to claim that your injuries were not as severe as you stated.
- Providing inconsistent information: Be consistent and truthful in reporting your symptoms and pain levels to your healthcare providers. Inconsistencies in your medical records could be used against you.
- Not keeping personal records: Your actual medical records are important, but your own records can be, too. You might wish to track pain levels, treatments, and limitations in your daily activities in a medical journal. This can help strengthen your claim.
Consult a Massachusetts Personal Injury Lawyer to Protect Your Rights
Medical documentation is one of the most important factors in a successful personal injury claim, whether you’ve been injured in a car accident or a medical malpractice case. Your medical records provide the necessary proof to establish liability and pursue fair compensation.
If you or a loved one has been injured due to someone else’s negligence, don’t leave your case to chance. Contact our skilled Massachusetts personal injury lawyers at the Fogelman Law Firm. We can help ensure that your medical records are properly obtained, reviewed, and presented to support your claim. Call (617) 559-1530 or complete our online contact form to start with a consultation.
