Causal relationship is the physician's opinion that the injury sustained and the mechanism of injury are compatible as reported. This is needed both on the First Report of Injury (FROI) when filed, or when a new condition is being recommended. It is your written supportive opinion that the condition is a result of the original injury and/or previously allowed condition(s)/diagnoses in the claim. This opinion of causality is essential to directly link the alleged medical diagnosis to the workplace injury. Without this opinion from the physician, it is difficult for our claims service specialists to process the request.
To assist treating physicians, BWC provided on the First Report of Injury (FROI) and Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) areas to indicate whether or not the alleged condition is causally related to the claim. The physician requests additional conditions on the Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9). Please provide your explanation there or in the progress notes. When forming your opinion on causality or causal relationship, physicians should rely on historical information available to them including that provided by their injured workers, exam results, any study results, and the physician’s knowledge and expertise.
Physicians are only expressing their opinions. It is understood that they may not have all the information at the time of completing forms and may have opinions that differ from others. However, physicians' expressed opinions are essential in processing claims and determining the allowed conditions.
Basis for the causality or causal relationship
For workers' compensation purposes, the standard or threshold to be attained for establishing the relationship is more likely or probable than not, which equates to a greater than 50 percent likelihood of the alleged diagnosis or condition being work-related.
To address causality or causal relationship for BWC claims, the examining physician should understand the legal definitions and requirements. Ohio Revised Code 4123.01 provides the following definitions:
- "Injury" includes any injury, whether caused by external, accidental means or accidental in character and result, received in the course of, and arising out of, the injured employee's employment;
- "Occupational disease" means a disease contracted in the course of employment, which by its causes and the characteristics of its manifestation or the condition of the employment results in a hazard which distinguishes the employment in character from employment generally, and the employment creates a risk of contracting the disease in greater degree and in a different manner from the public in general.
The Ohio Administrative Code 4123-3-09 states the "the burden of proof is upon the claimant (applicant for workers' compensation benefits) to establish each essential element of the claim by preponderance of the evidence." One of the essential elements the injured worker must prove is “That the alleged injury or occupational disease was sustained or contracted in the course of and arising out of employment.”
Note: For workers' compensation purposes, the standard or threshold to be attained for establishing the relationship is more likely or probable than not, which equates to a greater than 50 percent likelihood of the alleged diagnosis or condition being work-related.