By: Shay Jacobson, RN, MA, NMG, LNCC, CNLCP
Martha Kern

It seemed to be a straightforward case: A woman was walking on a city sidewalk, tripped over a one-quarter-inch ridge where two sidewalk sections met, and fell. She filed an $800,000 lawsuit against the

city alleging that the sidewalk was faulty.

The woman sustained several injuries, among them a torn rotator cuff and debilitating back pain of unknown origin. Multiple diagnostic tests failed to show a cause for her back pain, though the plaintiff insisted the pain stemmed from the fall.

Lifecare Innovations was hired by the defense in this case to review the medical records and assist in determining if the claim had merit.

Records Provided and Records Discovered

We were provided only with the ortho records from the incident. It was reported to us that no other records were available. Treating physicians, apparently relying on anecdotal information from the plaintiff, noted “previous history unremarkable”.

The post-morbid records showed that the plaintiff was relying heavily on narcotics to manage her pain. She returned to the medical team many times to continue use of pain medications.

It was further shown that the plaintiff, a homeless woman, was a recipient of Medicaid benefits.

It was on this fact that the entire case would come to hinge.

We requested Medicaid billing records for the plaintiff. The records showed the billing codes which enabled us to back our way into the plaintiff’s medical history. As it turned out, the plaintiff’s medical history was anything but “unremarkable”.

History Repeats Itself

The Medicaid billing records showed a very active history for the plaintiff. There were billing codes for over 1000 psychiatric appointments over the course of five years. There were also codes for eight inpatient drug rehabilitation attempts, suggesting a significant history of drug abuse.

The plaintiff was using psychotropic drugs that cause unsteadiness at the time of the incident. Per the record, she had been treated for eight previous falls, one of which had occurred just 20 days before the incident at hand.

We recommended to the defense team that they go back to the treating orthopedic physicians with the following questions:

  • If the plaintiff’s medical history had been known, would you have amended the treatment plan?
  • Might the plaintiff’s complaints of back pain, for which diagnostic testing has shown no discernable medical cause, be reflective of drug-seeking behavior?

The plaintiff’s medical history was also a revelation for her legal team. Had they known of her history prior to filing suit, they might not have pursued the case.

The case did not move forward. In fact, it could be said that the case itself tripped and fell over an unreported and very relevant history.

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