Using Your Medical Records to Support Your Personal Injury Claim

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Medical records are one of the most important pieces of evidence in personal injury claims, providing objective documentation of your injuries and treatment. While disclosing medical records may feel intrusive, it’s essential for building a strong case and is handled confidentially by legal professionals.

When pursuing a personal injury claim, your medical records play a vital role in establishing the extent of your injuries and their impact on your life. Here explain why medical records are so important, how they’re used in your claim, and address common concerns about privacy and disclosure.

Why Medical Records Matter in Personal Injury Claims

Medical records are the cornerstone of any personal injury claim, providing objective and detailed evidence of your injuries and their impact. They serve several purposes that can significantly influence the outcome of your case:

  1. Documenting injuries: Medical records provide a professional, unbiased account of your injuries. This documentation offers a clear timeline of your medical condition from the moment of the accident onwards.
  2. Establishing causation: One of the key elements in a personal injury claim is proving that your injuries were caused by the accident in question. Medical records can help link your injuries directly to the incident, strengthening your case.
  3. Detailing treatment: Your records outline all the medical care you’ve received, from emergency treatment to ongoing therapy. This information is vital in demonstrating the extent of your injuries and the efforts made towards your recovery.
  4. Demonstrating impact: Beyond just listing your injuries, medical records can show how these injuries have affected your daily life and work. This could include notes on physical limitations, pain levels, and inability to perform certain tasks.
  5. Calculating damages: The detailed information in your medical records helps in determining appropriate compensation. This includes not just current medical expenses, but also projections for future care needs.

By providing this comprehensive view of your injuries and their consequences, medical records form the foundation upon which your entire claim is built.

Types of Medical Records Used in Claims

Personal injury claims may draw upon a wide range of medical documentation to build a complete picture of your injuries and their impact. The types of records used can vary depending on the nature and severity of your injuries, but commonly include:

  • GP records: These provide a history of your health before and after the accident, which can be key to establishing the impact of your injuries.
  • Hospital admission and discharge notes: These documents offer detailed information about your immediate post-accident condition and the initial treatment you received.
  • Surgical reports: If you required surgery as a result of your injuries, these reports provide in-depth information about the procedures performed.
  • Diagnostic test results (X-rays, MRIs, CT scans): These offer objective evidence of your injuries, which can be particularly compelling in negotiations or court proceedings.
  • Therapy and rehabilitation records: These demonstrate the ongoing impact of your injuries and the efforts you’re making towards recovery.
  • Mental health treatment records: If you’ve experienced psychological trauma as a result of the accident, these records can support claims for emotional distress.
  • Medication histories: These can show the extent of pain management required and any side effects you’ve experienced from your treatment.

Each of these record types contributes unique and valuable information to your claim, helping to create a comprehensive picture of your injuries and their impact on your life. Your solicitor will review all available records to determine which are most relevant and persuasive for your specific case.

The Process of Obtaining and Using Medical Records

The process of obtaining and utilising medical records in a personal injury claim involves several steps to build a strong case:

  1. Consent: The first step is obtaining your consent. You’ll need to sign a medical release form allowing your solicitor to access your records. This form typically specifies which healthcare providers can release your information and for what time period. It’s important to read this form carefully and ask any questions you might have before signing.
  2. Retrieval: Once consent is obtained, your solicitor will request relevant records from your healthcare providers. This can include your GP, hospitals, specialists, and any other medical professionals who have treated you in relation to your injury. The retrieval process can take several weeks, as healthcare providers often have a backlog of record requests to process.
  3. Review: After receiving your records, a medical expert will thoroughly examine them. This expert is usually a specialist in the field relevant to your injuries. They’ll review your medical history, the details of your injury, treatments you’ve received, and your prognosis. This review is crucial in understanding the full extent and impact of your injuries.
  4. Report: Based on their review of your records and potentially a physical examination, the medical expert will produce a detailed report. This report will typically include:
    • A summary of your injuries
    • An opinion on whether your injuries are consistent with the accident described
    • Details of your treatment and recovery
    • A prognosis for your future health and any ongoing care needs
    • An assessment of how your injuries have affected and may continue to affect your life
  5. Negotiation: Your solicitor will use this medical report as a key piece of evidence in negotiating your compensation. They’ll use the information to argue for a settlement that fully accounts for your injuries, treatment costs, and the impact on your life.

Throughout this process, your solicitor will keep you informed and may ask for additional information or clarification as needed. It’s a thorough and sometimes lengthy process, but it’s essential for building a strong, evidence-based claim for your compensation.

Addressing Privacy Concerns

It’s natural to feel apprehensive about sharing your medical history. The idea of strangers poring over your personal health information can be uncomfortable. However, it’s important to understand how this information is handled and protected:

  • Only relevant information is used in your claim: Your solicitor will only request and use medical records that are directly relevant to your injury claim. They won’t be looking at unrelated medical history unless it has a bearing on your current injuries.
  • Your records are handled confidentially by legal and medical professionals: All parties involved in reviewing your medical records are bound by strict confidentiality rules. This includes your solicitor, medical experts, and even the opposing party’s legal team.
  • Disclosure is limited to parties directly involved in your claim: Your medical information won’t be shared with anyone who isn’t directly involved in assessing or negotiating your claim.
  • You have the right to review any medical reports before they’re shared with the other party: This gives you the opportunity to check for accuracy and raise any concerns before the information is used in your claim.

Remember, the purpose of disclosing your medical records is to support your claim and ensure you receive fair compensation. The professionals handling your case understand the sensitive nature of this information and have systems in place to protect your privacy.

The Importance of Full Disclosure

While it might be tempting to withhold certain medical information, especially if you think it might negatively impact your claim, it’s important to be fully transparent:

  • Failing to disclose relevant medical history can severely damage your claim: If it’s discovered that you’ve withheld important medical information, it could undermine your entire case and potentially lead to accusations of fraud.
  • Pre-existing conditions don’t necessarily hurt your case and may even strengthen it if the accident exacerbated them: In fact, if the accident has worsened a pre-existing condition, this could potentially increase your compensation.
  • Your solicitor needs complete information to build the strongest possible case for you: Without full disclosure, your solicitor can’t anticipate potential challenges to your claim or develop strategies to address them.

Being honest and upfront about your medical history allows your solicitor to present your case in the most accurate and favourable light. It also prevents the risk of your claim being undermined by information that comes to light later in the process.

What If You Refuse to Disclose Medical Records?

Refusing to disclose your medical records can have serious consequences for your personal injury claim:

  • It may be seen as a breach of your agreement with your solicitor: When you engage a solicitor, you typically agree to provide all necessary information for your claim. Refusing to disclose medical records could be considered a violation of this agreement.
  • You could face financial penalties for costs incurred by your solicitor: If your solicitor has already begun work on your case and you then refuse to provide medical records, you might be liable for the costs they’ve incurred up to that point.
  • Your claim may be significantly weakened or even dismissed: Without medical evidence, it’s extremely difficult to prove the extent of your injuries and their impact. This could result in your claim being undervalued or, in some cases, thrown out entirely.

It’s important to understand that while you have the right to refuse disclosure, doing so can effectively end your claim. If you have concerns about disclosing your medical records, it’s best to discuss these with your solicitor. They can often address your worries and explain why the information is necessary for your case.

Challenging Inaccuracies in Medical Records

Sometimes, you may find that your medical records contain errors or inaccuracies. This is not uncommon, but it’s crucial to address these issues promptly:

  1. Discuss the discrepancies with your solicitor immediately: If you notice any errors in your medical records, inform your solicitor as soon as possible. They can advise you on the best course of action.
  2. Your solicitor can help you request corrections from your healthcare provider: In many cases, simple errors can be corrected by contacting the healthcare provider directly. Your solicitor can guide you through this process or handle it on your behalf.
  3. If necessary, you can provide a written statement explaining any inaccuracies: If the healthcare provider is unwilling to amend the records, or if the process would take too long, you can provide a written statement detailing the inaccuracies. This statement can be included with your medical records when they’re submitted as part of your claim.

It’s important to note that challenging inaccuracies doesn’t mean trying to hide or alter unfavourable information. The goal is to ensure that your medical records accurately reflect your condition and treatment. Honest and accurate medical records are crucial for building a strong and credible personal injury claim.

Using Medical Records to Maximise Your Claim

Your medical records are not just a requirement for your claim; when used strategically, they can significantly strengthen your case and potentially increase your compensation. Your solicitor can use your medical records in several ways to maximise your claim:

  • Highlighting the severity and long-term impact of your injuries: Detailed medical records can paint a clear picture of how serious your injuries are and how they might affect you in the future.
  • Demonstrating the need for ongoing treatment or care: If your injuries require long-term or permanent care, your medical records can help justify claims for future medical expenses.
  • Showing how the injury has affected your ability to work: Medical records can provide evidence of how your injuries have impacted your capacity to work, supporting claims for lost earnings or reduced earning capacity.
  • Proving the necessity of any lifestyle adaptations you’ve had to make: If your injuries have required you to make changes to your home or daily routines, medical records can help justify these expenses as part of your claim.

By thoroughly analysing your medical records and presenting the information effectively, your solicitor can build a compelling case for the full compensation you deserve.

Frequently Asked Questions

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Comments & Questions

Read on for questions and advice about claiming...

If my medical record were given to my employer by my doctor without me seeing them after I had instructed this to be done has my doctor broken the law or confidentiality?

Ian Morris

Your GP cannot disclose your medical records without your consent to do so.

Reply

I fell over a raised grid and I have a no win no fee solicitor, it looks as if I may have to go to court to try to obtain the compensation due to me. I have been to all the different specialists which my solicitor arranged for me to do, one of the specialists recommended I have an mri scan as I suffer from headaches, my own doctor says I don’t need one but my solicitor has arranged for me to go privately as my headaches are a lot better now and I went for an eye test but she insists I still go even though they are paying. I am terrified to go as I have claustrophobia, do I still have to go as she requested?

Ian Morris

Whatever you do, don’t just fail to turn up. If you have anxiety issues around any aspect of your claim, make sure that you discuss them fully with your Solicitor. Your Solicitor is there to help you and act in your best interests. Whatever the issue, as long as your Solicitor knows of your concerns or problems, they can help to make sure that those issues don’t damage the prospect of succeeding with your claim.

Reply

I was involved in an RTA of which the other driver claimed full liability. I subsequently remain off work due to my injury and have been for a number of months. I was currently off sick on the day of the RTA whilst recovering from major surgery but had been due to return back to work a week following the date of the RTA. My major surgery recovery had been slow and I had pre existing health problems which the medics think may have played a part in my delayed recovery.
Am I better allowing only my medical notes since the RTA to be forwarded to the insurers or my full notes? Some of my pre existing health problems may clearly be delaying my injury now ie previous back surgery years ago and chronic pain from a previous injury.
I have already experienced in the past how defence medics & solicitors use any possible thing they can and even lie ( despite clear supporting evidence/history being documented in a persons medical notes) to twist every past illness/surgery or ailment a person has ever had and have great concerns they will see this as an opportunity to use against me in any way possible. So am I better allowing only medical evidence since my RTA to be forwarded? The whole experience was so unpleasant despite me being prior warned this is the norm legal behaviour and hoped never to go through anything similar again but sadly I now find myself in this dreadful situation through no fault of my own at all.

Ian Morris

Do you have a Solicitor acting for you in this matter? If not, please contact us on 01225430285 so that we can advise you further and have this matter pursued by an expert specialist Solicitor.

If you already have a Solicitor, it is important that you disclose any pre-existing conditions to the Solicitor at the earliest opportunity. That way, they can ensure that an appropriate medial expert is instructed to provide a detailed report that would outline the way that the recent trauma of the car accident has caused both new injuries and importantly, exacerbated pre-existing conditions or caused a delay in your healing process. It is always best that this information is known BEFORE the 3rd party get a chance to ‘discover’ the pre-existing conditions and attempt to use them to discredit you or your claim.

Solicitors are well used to including pre-existing conditions in a claim and if they know the full details, they can ensure that the defendant is unable to wriggle out of their liabilities in your claim.

Reply

An at-fault driver’s solicitor has asked to see my friend’s complete medical records from birth. Are they allowed to do this?
Mary

Ian Morris

The defendant can request sight of a claimants medical records. They will do this in order to be certain that there are no pre-existing issues or ongoing problems that were already being dealt with by Doctors as if they can find such evidence they can reduce the amount of compensation that they may have to pay. Whilst this is a totally legitimate request, your friend doesn’t have to agree to their request and she should discuss the request with her Solicitor and seek their advice as to what is best to do.

Reply

I appreciate your responses. And apparently they want to see medical reports, even though they have had physio report, and a independent gp report that says my injuries, was because of the accident, but I’ve now seen a orthopedic surgeon, and awaiting for my medical records that I’ve signed to be released.

Ian Morris

Whilst this further requirement to go through all sorts of records and reports is clearly frustrating for you, you should not let it concern you too much. It seems that your Solicitor is handling the matter correctly and all of the records that the defendant wants to see will only help in establishing the severity of your injuries and therefore a valuation on your claim for compensation.

Reply

I really hope you can help.

I’m part way through a claim where the solicitor has said I need to accept the medical report from the specialist doctor even though I entirely disagree with it. Can I request a different specialist doctor? Or do I start from scratch with a different solicitor? My reasons for disagreeing a substantial and I have evidence.

I was on a bicycle and went over the bonnet of a car who pulled out on me. The driver claimed full responsibility and have two witnessed who agreed.

I was unable to walk properly immediately afterwards due to a big knock on the knee, but still went into work the next day due to my employer not paying for any time off. ie. I had one day off work (the day of the accident) to rest my knee.

The medical report came back twice stating “NO TIME OFF WORK WAS NECESSARY”. This goes against both the ambulance report and GP reports that both advised rest.

The medical report even stated that “in his opinion, the accident would have caused me pain at work”.

It just seems bizarre to me so I’m stuck as to what to do! At the VERY lest I expected to be able to claim ONE day of lost earnings back. This was my main reason for claiming.

Ian Morris

It is not uncommon for a claimant to note discrepanices, small errors or missing items in a medical experts report. Any such errors should be identified and noted and returned to the expert for amendment of their final report prior to agreeing to the report and sharing the contents with the defendant.

The issue you mention in your specialist report regarding the time off work should be an issue that is easily amended and your employer should be able to provide confirmation of any days of absence at the accident date or afterwards as further evidence.

There is no realistic prospect of switching Solicitors given the nature of No Win No Fee and the fact that a new Solicitor would have to ensure that the previous Solicitor received fees for the work that they have done upon settlement of the claim, making such a move financially unviable for the new Solicitor. With regards to a new medical expert, you can request a 2nd report, but you would have to meet that cost personally (you can’t recover the cost of a 2nd medical report) and there is of course, no guarantee that a new expert would provide a more beneficial report.

If you are not happy with your Solicitor and their handling of this issue (or any other element of the claim), you should make a formal complaint to them in order that a senior partner within that firm investigates your concerns and hopefully resolves it for you.

Reply

I had a nasty accident at home falling downstairs and damaging my foot badly. I had an xray and it showed a closed fracture of the foot. I have had 3 more xrays because it wasn’t getting any better it showed that I never had a fracture. I have this in writing off my GP, Hospital and Podiatrist that it was broke, but now they are denying it. Have I got a claim. I am at present wearing an air boot after 8 months of the accident because the hospital never treated it. I am left disabled, I have a bad limp and I can’t work.

Ian Morris

Clinical negligence is notoriously hard to confirm and equally hard to succeed with a claim for. However, we do have specialist Solicitors that can consider such claim scenarios and pursue such claims on a No Win No Fee basis if appropriate.

Reply

My partner had a accident in January this year but the driver drove off, although they managed to get the registration number of the other car.

He attended hospital and also saw his own doctor as he suffered whiplash injuries. His solicitor said that his personal injury claim had to go through MIB (which it is). He has had a medical with the medical advisor but now the MIB want his hospital and doctors records. Why do they need them if they have already got it from the medical advisor?

Ian Morris

It is most likely that the MIB have only received the medical experts report and not copies of the medical records. The record request is a standard matter and should not be something that you are concerned about. The reason that the MIB will want them is to confirm the nature of the initial treatment and what was reported by your partner on the visits he made. They’ll also want to see if he has any pre-existing injury symptoms that are linked to the injuries for which he is claiming.

Reply

Hi
I had my independent medical examination last week.The whole appointment lasted only 12 minutes and 3 of those minutes were used to examine me.The Dr seemed very disinterested and didnt ask any of the questions that were on the pre medical questionnaire they had sent me prior to my appointment.How he can do a fair and accurate report is beyond me…thanks

Ian Morris

If you have concerns about a medical examination by an expert, you should immediately inform your Solicitor (in writing) of your concerns and of the nature of the way you were examined.

Medical reports are vitally important in the process of reaching appropriate settlement in a claim for personal injury compensation. If the report is inaccurate or if the examiner fails to take in to account the full impact of the injuries or does not care to undertake a proper examination, a claimant could lose out on a substantial amount of just compensation. As such, you should contact your Solicitor about this urgently.

Reply

My employer hasn’t contacted me in over a year due to an injury at work, can they ask for my medical records without ever talking to me or even asking how I am? They have only asked for them because I asked if I was due any holiday pay, they said no but found out that I was.

Ian Morris

The employer can only obtain your medical records with your written consent to do so.

David

If I say no they want to send me to an occupational health therapist, what would be my best option, there are personal things on my medical records which I don’t want them to see

Ian Morris

You are within your rights to withhold personal and unrelated medical information from any party, particularly your employer. In your case, it would probably be wise to advise the employer that you do not wish to disclose your full medical history for personal reasons, but that you are happy to see an occupational health therapist.

Reply

I have a claim for whiplash & minor muscle injury. I’ve been upset with my legal team in general and we are many months on. They have now asked me for a lifetime of medical history, & I believe this is ridiculous for a small claim. I provided 3/4 years, my own legal team said no and it’s almost standard for a lifetime history to be asked for. I find it very hard to believe this? They have offered yesterday for me to open up full access or drop the cases or look for other legal representation. Again, they have been very poor, even to date they have not acted on important information I have presented to them. Is this something you could look at for me?

Ian Morris

The medical records issue you cite is not unusual and although it isn’t always requested, it can often be the case that a defendant insurer seeks such a history in order for them to be sure that the injury at the centre of your claim is not a long standing issue that you have previously been treated for. Whilst it is frustrating to be asked to provide this history, there is no reason for you not to release the records.

In terms of switching to a different Solicitor, it isn’t that straightforward and in the majority of cases, the best course of action is to remain with the firm you have already instructed. Before you do switch Solicitors, you should make a formal complaint to your existing Solicitor outlining the areas of their handling of your claim that has led to you feeling unhappy. This at least affords them the opportunity to resolve your complaint and hopefully leave you satisfied. If you can resolve your issue this way, it would be in your best interests.

Reply

Liability has been admitted for my personal injury claim and a Joint Medical Expert examined me in 2018 and produced a report for both my own solicitor and the other side’s solicitor. I am willing for the Expert to access my records from 2018 to date although there is not much to see but now the other side’s solicitors want to bypass the Joint Expert and get direct access to my records which is intrusive and I have refused. Am I within my rights to insist that only the Joint Expert can access my records and answer any legitimate questions the other side might raise so that I do not have to waive my right to privacy and allow this solicitor to see my records? The expert report mentions GP entries dating back to 1993 and is not restricted just to the injuries I sustained in 2014 so it’s a very comprehensive report. What is the point of engaging a Joint Medical Expert if the defendant’s solicitor wants to bypass him like this?

Ian Morris

Your Solicitor should be able to advise you in this, but in general, there is no reason why the joint expert can’t be used to review your records and answer any specific queries the defendant may raise relating to your medical history or previous injuries relevant to the claim you are pursuing.

Reply

Can a solicitor ask for over 5 years worth of a medical record?

Ian Morris

Yes, if a Solicitor deems it appropriate to do so – either to prove that there was no previous injury or that an old injury was no longer something that required treatment until the index incident at the heart of a claim, a Solicitor will use the medical records as important evidence to support the work that they are doing.

Reply

Why do they want my medical record for the last 10 years?

Ian Morris

When you make a claim for personal injury compensation, the severity of your injury need to be proven, also a defendant needs to know that your injury was not present BEFORE the index incident for which you are making your claim. Therefore, a defendant checking your medical record history to confirm that you have not previously complained of the injury that forms the basis of your claim is valid and fair.

Reply

My GP admitted negligence but my claim was denied. After a meeting at my practice with the manager I was issued with my medical records so I could see if something was incorrect. There was a serious error and it was agreed that an out of hours GP had seemingly mixed my notes up with another patient. As 3 years was now just past I have found it impossible to find someone to take the claim on again.
The GP practice has agreed to sign a time waiver form. Also as it was 10 months ago that the incorrect information came to light then would that now not be the time of awareness.
The situation is distressing especially as it has had life changing consequences for myself.
How can I go about a new claim?

Ian Morris

In terms of a claim for clinical negligence compensation, you should approach a specialist Solicitor who handles such matters exclusively. Clinical Negligence claims are notoriously hard to succeed with and should only be considered and represented by a specialist Solicitor with expertise and experience in claims of such a nature.

Reply

My husband was involved in a car accident. The other driver accepted liability. My husband sustained injuries which only became apparent a few weeks after the accident. He ended up in hospital and off work for a few months. He is refusing to sign for the release of his medical records. I don’t understand why as he had been fit and well for the last 22 years that I have known him. I think he is concerned about 3rd parties seeing his medical history. Friends & family have told him it is OK. What can be done to assure him it is OK. He is entitled to compensation and needs to co operate to get it.

Ian Morris

There is no reason for your Husband to have any concerns about disclosing his medical records to his Solicitor. The only elements of relevance within his medical history will be any previous medical treatments for injuries that form any part of his claim. For example, if your Husband injured his back in the accident, his medical records could show that he had a previous episode of back pain 10 years previously. If this were the case, the defendant insurer would be within their rights to query whether the previous ‘injury’ or issue was linked to the new one and needed to be considered when settling the claim.

His medical records will not be made available for public view – only by the two sides who are being represented in his claim.

Without release of his medical records, he will receive some compensation but the value of his settlement is likely to be far, far lower than it should be if his medical records were made available to support his claim.

Reply

Can my solicitor use my original injury medical report after 3/4 as the claim is due to go to court soon . Solicitor asking me to provide a new medical, but why can’t they use the same medical records when I was injured at work. To me it makes sense to use the original as that tells the court what my injuries was and my operations I had .

Ian Morris

It is always sensible to act on the advice of your Solicitor as they are duty bound to act in your best interests. The new medical report may well be needed to demonstrate that the injuries have not healed and prove how they are continuing to impact on you.

laura

Thank you for your reply

Reply

I had slip and fall at work injured my neck, they accepted liability but I must wait for causation, how far back do medical experts Look back in medical records?

Ian Morris

If you have any relevant issues regarding problems with your neck, that could be seen as relevant and may be called in to question. However, if you have lived years symptom free with no medical intervention, you probably won’t have any concerns.

Reply
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