Telehealth and Your Injury Claim: Keeping Treatment Consistent

Published May 21, 2020 · Injury Law Basics

Ten minutes on a laptop at the kitchen table does not feel like a doctor's appointment. There is no waiting room, no paper gown, and the doctor never touches the shoulder that has been keeping you up at night. But for many people recovering from a crash or a fall this spring, a video or phone visit is the only care available, and how you handle it matters more than you might think.

Here is the reason, in one sentence: in an injury claim, the medical record is the case. A telehealth visit that is well documented keeps that record continuous. A missed visit leaves a gap that an insurance adjuster will try to use against you.

Why consistency matters so much

Earlier this month I wrote about keeping an injury claim on track during the COVID-19 slowdown. The central problem is the "gap in treatment." When the record shows weeks or months without care, insurers argue that you must have recovered, or that your current problems came from something else. Our guide chapter on focusing on treatment explains why that argument is so often unfair, and why it still works on adjusters and juries.

A canceled appointment because a clinic closed is not your fault. But six weeks of silence in the chart looks the same on paper whatever the reason. A telehealth visit fills that space with a dated note from a medical professional describing your symptoms, your limitations, and the plan going forward. That is exactly the kind of evidence a claim is built on.

What a video visit can and cannot show

It helps to understand what your provider can document remotely, so you can fill in the rest.

A video visit can capture:

• Your description of pain, its location, and how it has changed
• What you can and cannot do at home and at work
• Visible swelling, bruising, scarring, or a healing incision
• How you move: walking across the room, standing up from a chair, raising an arm, turning your head
• Medication use, side effects, and sleep problems
• Mental-health symptoms such as anxiety, flashbacks, or trouble concentrating
• Referrals, prescriptions, and the treatment plan

A video visit cannot do:

• A hands-on exam: pressing on a tender spot, testing strength against resistance, checking reflexes
• Imaging, injections, or procedures
• Some of the specific tests a specialist would normally perform in the office

Because the provider cannot feel or test what is wrong, your words carry more weight than usual. The note will reflect what you say, and very little else.

How to make each visit count

Prepare a short list before the call. Write down every symptom, from head to toe, including the ones that seem minor or that you mentioned last time. Headaches, numbness, ringing in the ears, dizziness, memory problems, and trouble sleeping all belong on the list. Doctors chart what you tell them, and a symptom that is never mentioned is a symptom the insurer will say you never had.

Describe function, not just pain. "My back hurts, about a six" is useful. "I can't sit for more than twenty minutes, I can't lift my laundry basket, and I've been sleeping in a recliner" is far more useful. Specific, everyday examples tell the doctor, and later the adjuster or jury, what the injury is doing to your life.

Connect it to the injury. At each visit, it is fair to remind the provider why you are being treated: "This is follow-up for the injuries from my March 2 car crash." Ask that the note reflect that your complaints are related to the crash or fall. Providers handle many patients; a one-sentence reminder keeps the history straight.

Show what can be seen. Use good lighting. Show the swelling or the scar. Demonstrate the movement that hurts. If your provider's patient portal allows it, upload dated photos of bruising or a wound so they become part of the chart.

Be honest in both directions. Do not minimize because you are tired of being hurt, and do not exaggerate because you are worried about your claim. Credibility is everything, as I wrote years ago in a post on honesty with your doctor. That advice applies on a screen as much as in an exam room.

Ask about the next step. Before the call ends, ask when you should be seen in person, whether imaging or a specialist referral is needed, and what to do if symptoms get worse. Then follow through.

Physical therapy at home

Many physical therapists are now offering video sessions and home exercise programs. If yours does:

• Attend every scheduled remote session, just as you would in the clinic.
• Do the home program as prescribed, and keep a simple log: date, exercises, repetitions, and how you felt during and after.
• Tell the therapist about anything you cannot do or that causes increased pain, so it is written in the therapy notes.
• If your therapist cannot see you remotely, ask for a written home program and a note in your chart explaining why in-person therapy was paused.

Therapy records are often the most detailed picture of how an injury limits a person day to day. A log of home sessions, kept faithfully, helps bridge the time until the clinic reopens.

Phone visits

Not everyone has video, and some providers are using telephone visits. They are better than nothing, but they document less. Be especially thorough in describing your symptoms and limitations, and ask the provider to schedule an in-person or video follow-up as soon as one is available.

Getting the records

Telehealth visits generate notes the same way office visits do, but they are sometimes stored in a different part of the provider's system. When records are requested for your claim, the request should specifically include telehealth and telephone encounters, patient-portal messages, and any photos you uploaded. Our guide chapter on preserving documents and records explains how to keep your own copies organized, including visit summaries and portal messages, which you can usually download or print yourself.

What this means for you

• Keep every appointment, in whatever form it is offered.
• Prepare for each telehealth visit with a written symptom list and concrete examples of what you cannot do.
• Remind the provider that your treatment is for injuries from the crash or fall.
• Log your home exercises and keep a short symptom journal between visits.
• Return to in-person care as soon as it is available, and document why you could not go sooner.

You can read more about the injury cases we handle on our personal injury page.