Education
When the Law Requires Proof, the Claim Depends on the Records
California’s new SB 171 significantly changes how Subsequent Injuries Benefits Trust Fund (SIBTF) claims will be evaluated and proven. For claims professionals, the biggest takeaway is simple: preexisting conditions must now be supported by meaningful, timely documentation.
A diagnosis in someone’s medical history may no longer be enough. The evidence must show that the condition affected the employee’s ability to work before the subsequent industrial injury.
What changed
- A prior condition must have caused lost earnings, interfered with work activities or otherwise affected the employee’s ability to work.
- The prior condition’s impact must be supported by evidence that existed before the subsequent injury.
- A condition controlled by medication or a medical device may not qualify if the employee could work without incapacity.
- Medical evaluators must address the prior disability in a medical-legal report supported by substantial evidence.
- Multiple impairments must be combined using the Combined Values Chart rather than simply added together.
- New filing deadlines apply.
- Many pending SIBTF claims are subject to the new requirements, although certain older claims and cases that reached specific procedural milestones are protected.
What this means for claims handling
Claims professionals will likely see greater attention placed on prior medical conditions during the underlying claim.
The important question is no longer just, “Did the employee have a preexisting condition?” Claims teams must also determine what effect that condition had on the employee’s ability to work.
Relevant evidence may include:
- Prior medical records and disability awards
- Work restrictions or modified duties
- Lost time or reduced earnings
- Workplace accommodations
- Previous workers’ compensation claims
- Medical treatment, medication and assistive devices
Obtaining this information early allows the medical evaluator to consider the complete history and prepare a report supported by the appropriate evidence. Missing or incomplete records may affect SIBTF eligibility, impairment ratings, apportionment and the timely resolution of the claim.
The connection to copy services
This reform directly reinforces the importance of professional record retrieval.
The necessary evidence may be held by several different custodians, including prior medical providers, former employers, workers’ compensation carriers, WCAB offices, occupational clinics, pharmacies and human resources departments.
This does not mean requesting “any and all records” from every possible source. Effective retrieval requires identifying the correct custodians, using appropriate date ranges and requesting the specific records needed to answer the claims question.
Copy services help claims professionals and their attorneys retrieve authenticated records, document the source of the evidence, and organize the information for efficient review.
SB 171 may change the legal requirements, but it also reinforces something I have said for years:
When the law requires proof, the claim depends on the records.
Sources: WorkCompCentral article | Official SB 171 text