Do I need to disclose all my medical records in a personal injury claim?

Whether or not you will need to disclose all your medical records in a personal injury claim depends on the circumstances of the accident and the injury sustained. Let’s go into more detail about the personal injury claims process and whether disclosure of medical records in personal injury cases is necessary.

Medical Records may be needed to prove the injury, its severity and sometimes prognosis

In order to bring a successful personal injury claim, you will need to prove that the accident caused or at least contributed to your injury. In order to do this, your solicitor will need to obtain expert medical evidence. This is usually in the form of a report, prepared by an independent medical expert. The expert will also report on your condition and the prognosis of your injury.

In some low value claims, the medical report will be prepared by an independent GP expert. In these cases, the medical report will be based on the information provided by the injured patient and the information obtained by the doctor during an appointment and examination of the injured person. In these types of cases medical records will probably not be required and therefore disclosure of medical records in these personal injury cases is not necessary.

Disclosure of Medical Records in Personal Injury Cases – Serious Injuries

If, however, you have sustained a more serious injury as a result of an accident, and decide to instruct solicitors to bring a personal injury claim, at the start of the personal injury claims process you will be asked to sign a form of authority so that the solicitor can apply for copies of your medical records. This includes GP records, hospital notes, x-rays and scan results, dental records and documents held, for example, by physiotherapists. The records applied for will cover the period before and after your accident.

Your solicitor will then review the medical records, prior to instructing the independent medical expert to prepare a report. The medical records should provide information in respect of the following:

• Your health prior to the accident and whether you have any significant previous medical conditions/injuries/diagnoses/vulnerabilities that your solicitor needs to be aware of and that could have an impact on your personal injury claim.
• The details of your injury, your diagnosis and the treatment that you have received to date and your response to this treatment.
• In some instances, the circumstances of the accident which has caused your injury.

Disclosure of Medical Records in Personal Injury Cases – Specialist Medical Experts

In more serious injury cases, the independent medical expert (a specialist in relation to the particular injury sustained, such as a consultant orthopaedic surgeon) will not only examine the injured person, but will also review their medical records. The expert will consider any relevant previous medical history, the extent of the injury and the response to treatment. The expert will also set out recommendations for treatment going forward.

In some straightforward cases, the expert report will be disclosed to the Defendant, their insurers or solicitors and the other side will not request copies of the injured person’s medical records.

Your medical records and their use in the personal injury claims process

However, in more serious or complex injury cases, it is more likely that the other side, usually the Defendant’s solicitor, will request copies of the injured person’s medical records.

Prior to disclosure, your solicitor will obtain your authority to disclose your medical records.

In some cases the Defendant’s solicitor may only ask to see records which have been obtained from a specific hospital or covering a particular period. They may request copies of only some records which they consider to be relevant. In these instances, not all medical records will be disclosed.

The Defendant’s solicitor will also review the medical records that they have requested, prior to instructing their own medical expert to prepare an independent medical report (generally in higher value cases) on the cause of injury, the injured person’s condition and prognosis.

The Defendant’s solicitor will also consider the injured person’s previous medical history, the extent of the injury sustained as a result of the accident, the diagnosis and the treatment received. This solicitor may also want to review the records to check whether the injured person has exaggerated their symptoms or the extent of the injury.

What happens if you refuse to provide your medical records in the personal injury claims process?

If an injured person refuses to provide the other side with a copy of their medical records, the Defendant’s legal representatives can make an application to the Court, to seek a Court Order for the release of the records. The Court will order that the medical records are disclosed if this is necessary for the case to be dealt with properly. If the injured person fails to comply with the Court Order, there could be serious consequences. The case could be struck out and no compensation awarded.

Disclosure of Medical Records in Personal Injury Cases – Is it always necessary?

Essentially, you will not necessarily always need to disclose all your medical records. It depends on the nature of your injury and the circumstances of the case. In bringing a personal injury claim however, you should be prepared that it will probably be necessary to disclose at least some of your medical records, in order to make sure that the case is properly dealt with and that you are adequately compensated for the injury that you have sustained.