The Adjuster on the Phone and the Patient Who Wants “100% Disabled”

You may not answer the question as posed, in the way it was posed.

Sequence:

1. Do not confirm clinical details verbally to an unverified caller. A claims adjuster's identity and authorization must be established before any disclosure.
2. Verify a signed, dated authorization from the patient that names the payer and the scope, or confirm the statutory workers' compensation authorization that applies in your jurisdiction. Workers' compensation statutes commonly permit release of work-related records to the carrier without a separate authorization - but the scope is the work injury, not the whole chart.
3. Respond in writing, on a standard work-status form, on your letterhead, within your normal turnaround. Say: “I can't discuss this by phone. Fax me the authorization and the specific questions, and I'll respond in writing by [date].”
4. Answer only what is asked: current work status, objective findings, restrictions, treatment plan, expected duration, next re-evaluation date.

What you do not send: the full chart. The motorcycle crash and the PTSD treatment are outside the compensable injury and outside the request's legitimate scope unless the patient authorizes it or the jurisdiction requires it. Release the minimum necessary for the specific purpose.

Why this matters: a casual verbal “yeah, he's fine to lift” to an adjuster is a clinical opinion delivered without examination of the question, undocumented, and unretractable. Written responses are reviewable and correctable.

Both requests must be declined, but they are declined differently.

1. “Write that I'm 100% disabled.” You cannot document a clinical finding you do not believe. That is not advocacy; it is a false statement in a medical record, and depending on jurisdiction it is insurance fraud, with your license attached to it. Your findings - 3/10 pain, 65° flexion, 30 minutes walking - do not support total disability.

Say it without moralizing:

“I can't write that, because it wouldn't be true to my exam, and a report that doesn't match the record would hurt you more than it helps. What I can do is document exactly what you can and can't do, in numbers. That's what actually carries weight.”

Reframe what he is really asking for. He wants the settlement to reflect his limitations. The document that serves him is an accurate functional capacity description - and it may support more restriction than he expects in some domains (e.g., repetitive lifting tolerance).

2. “Don't send the motorcycle crash or the PTSD records.” You do not selectively omit records to shape a claim. But you may also decline to volunteer unrelated records - the correct answer is scope, not concealment:

• The prior motorcycle injury may be relevant to causation and apportionment, particularly if it involved the lumbar spine. If it does, withholding it is misrepresentation.
• The PTSD treatment is almost certainly outside the compensable injury and outside the carrier's legitimate need unless the patient puts it at issue (e.g., by claiming psychological injury).
• Tell him honestly which records fall inside the work-injury scope and which don't, and let him decide how to proceed with informed understanding. Do not agree to a plan that requires you to falsify or omit relevant material.

Never alter or backdate a record, and never add a restriction you did not assess in order to support a claim.

Provide a written work-status/functional capacity summary containing objective, measured data:

• Diagnosis and mechanism, with the work-related attribution stated.
• Objective measures with dates: lumbar flexion 65° (from 30°), pain 3/10, continuous walking tolerance 30 minutes.
• Functional testing performed in clinic: repeated lift tolerance, sit-to-stand, tolerance for sustained postures - measured, not estimated. If you cannot measure it, say so rather than guess.
• Work restrictions stated in the employer's language: e.g., “may lift up to 25 lb occasionally from floor to waist; no repetitive trunk flexion beyond 30 minutes per hour; sit/stand alternation as needed; no unrestricted lifting.”
• Treatment plan, expected duration, and next re-evaluation date.
• Explicit statement of what was not assessed - e.g., “no formal functional capacity evaluation performed.”

Consider referring for an FCE if the settlement hinges on lifting capacity. An independent, standardized FCE is more defensible than your in-clinic estimate and it protects you from being asked to be the arbiter of a dollar figure.

Defensibility checklist:

• Every statement traceable to a dated entry in the chart.
• Restrictions tied to measured findings, not to the patient's request.
• Nothing released beyond the authorized scope.
• The patient's requests and your responses documented in the record (in neutral language: “Patient requested documentation of total disability; explained that findings do not support this; offered functional documentation instead.”)
• Documentation that you explained the limits of confidentiality and the scope of release to the patient.

Stay in your lane on the settlement: your role is to describe impairment and function. Whether he is “disabled” for benefit purposes is a legal determination, and saying so plainly is both accurate and protective.