This MVA-related claim illustrates the importance of ensuring that all prior records are obtained as well as the importance of factoring multilevel degenerative pathology into the analysis.

In this case, a 60-year-old male, restrained driver of a semi-tractor trailer struck the right back of another tractor trailer that ran a stop sign in front of him as the claimant was turning left. The claimant did not seek medical care until the next day and was diagnosed with a cervical hyperextension injury.

He later switched providers — with no reported motive — and began seeing an orthopedic, neurologist, and neurosurgeon.  The claimant underwent cervical and lumbar facet injections and was recommended to have future care including rhizotomies, spinal cord stimulator, and discogram.

This plaintiff alleged that the accident caused significant cervical and lumbar disc herniations, bilateral knee sprains, left shoulder sprain, and brain infarct.  He listed all billed diagnoses — a total of 42 — as a result of this MVA and made a demand for $1 million.

Mechanism of Injury (MOI)

The claimant’s report of the MOI to the providers was mostly consistent with the police report.  There was a discrepancy in one report of the MOI, in that the claimant rear-ended another vehicle.

There were also discrepancies regarding airbag deployment.  The police report noted they had deployed, but the claimant reported that they had not.

The claimant’s subjective complaint of neck pain correlates to the MOI. However, complaints of bilateral knee pain, left shoulder pain, and head pain do not correlate to the MOI, as he was restrained and denied hitting any extremity or his head on internal structures.  The speed of the accident was not such that the claimant would likely have sustained a brain injury.


A solid understanding of MOI is crucial to unraveling a complex MVA injury claim.  Here are some of the basics.

Comparison of pre and post Date of Loss (DOL)

Pre-DOL records were only from one health system and focused mostly on the claimant’s diabetes.  While it was noted that he had an MVA in 2015 in which he sustained a possible neck and head injury, no records were included related to that event.  An associated cervical MRI was performed at that time, and no records were included for that imaging.  He also had a prior ankle fracture and left shoulder rotator cuff injury.

There were several significant lapses in medicals in the pre-DOL records, including a nine-month month lapse prior to the DOL.  His true baseline status at the time of the DOL is unknown.

The claimant’s pre-DOL records continually pointed out the claimant’s lack of compliance with the diabetic treatment plan.  At one point, claimant told his provider that he wouldn’t comply because he did not have diabetes.

Inconsistencies

The claimant’s complaints continued to expand.  These included reports of numbness, although neurological exams were normal.  He appeared to be referred to specialists by his attorney without medical necessity.

The plaintiff attorney also alleged that multiple cervical and lumbar disc herniations found on MRIs were the result of this loss; however, imaging strongly supported significant degenerative pathology.

Other inconsistencies included the following:

  • A brain MRI revealed an area of old infarct which plaintiff attorney alleges is a result of this accident.
  • Records for a pre-DOL MRI were not included for comparison to post-DOL images.
  • There was no MOI for lumbar injury, bilateral knee injury, left shoulder injury, or head injury.  The claimant also denied hitting any internal structure, and there were no visible signs of trauma.
  • Future treatment recommended was costly and may have been noted to inflate the value of this claim.  Also, the recommended treatments were procedures directed at degenerative pathology.

Finally, the claimant received cervical and lumbar facet injections using a non-FDA approved substance that had no supporting clinical studies supporting its effectiveness.

Conclusion

The review of this claim significantly mitigated the overall exposure. Current medicals totaled $34,027, and future treatment estimates were over $500,000.  Since treatment was either unnecessary or directed at degenerative pathology, only three initial visits were recommended.  Some chiropractic care could have been recommended, but there were no records submitted from that provider.

Takeaways

  • It is important to ensure that all prior records are obtained.  With the multi-level degenerative pathology in this case, it is highly likely that the claimant had prior neck and back pain issues for which there may be other medical records.
  • Appropriate medical care should be just that, irrespective of the payer source.  Watch for changes in the details,  expansion of diagnoses and treatments and pre-injury conditions (diabetes, hypertension, etc.).  These conditions can profoundly impact post injury conditions and care.

KARI