Medical Record Review for Demand Letters: Attorney Checklist

Before sending a demand letter, confirm that the medical records support the claimed injury, causation, treatment, and damages. The review should also identify missing records, treatment gaps, preexisting conditions, inconsistent histories, intervening events, and other facts the insurer may challenge.

A demand-focused review should answer:

• Is the record set complete?
• Do the records support causation?
• Are treatment gaps explained?
• How do preexisting conditions affect the claim?
• Are damages and future care documented?
• What strengthens or weakens the demand?
• Is physician review needed?

What a Demand-Focused Medical Record Review Should Do

Medical record tasks are related but not interchangeable.

A medical chronology helps the legal team locate events. A medical record review assesses what those events mean for the demand.

Attorney Checklist Before Sending a Demand

1. Confirm Record Completeness

Compare the records received with the client’s treatment history, provider list, bills, and claimed injuries.

Check for:

• Ambulance, emergency, hospital, and surgical records
• Primary care and specialist records
• Imaging, laboratory, and pathology results
• Therapy, chiropractic, and rehabilitation records
• Pharmacy and medication histories
• Referrals and consultation reports
• Work notes and activity restrictions
• Prior records involving the same body part or condition
• Records after any later accident or intervening event
• Itemized bills, payment records, and balances
• Records supporting future treatment

Look for references to outside consultations, missing imaging, prescriptions without related encounters, or follow-up instructions without later notes.

Do not treat silence in an incomplete file as proof that an event did not occur. Obtain the missing records or disclose the limitation.

2. Build a Defensible Causation Timeline

The demand should connect the incident to the claimed condition without overstating the evidence.

Review:

• The client’s condition before the incident
• The reported mechanism of injury
• Symptom onset and progression
• The timing of the first evaluation
• Histories given to different providers
• Objective examination, imaging, testing, or surgical findings
• Provider statements addressing causation
• Competing explanations
• Later accidents, illnesses, or intervening events

Separate documented facts from the conclusions the demand asks the carrier to draw. Timing may support causation, but it may not establish whether a condition is acute, degenerative, aggravated, or unrelated.

Seek physician review when causation depends on interpreting imaging, distinguishing acute from chronic findings, or reconciling competing diagnoses.

3. Identify and Explain Treatment Gaps

Insurers often focus on delayed treatment, long gaps, missed appointments, and early discharge.

For each material gap, determine:

1. When it began and ended
2. What treatment was recommended
3. Whether symptoms improved or continued
4. Why treatment stopped or was delayed
5. Whether the reason appears in the records
6. Whether care resumed for the same condition

Possible explanations include referral delays, lack of insurance, transportation problems, work or caregiving duties, scheduling issues, illness, temporary improvement, or home-care instructions. Confirm the explanation with the client and available records.

Distinguish an unexplained gap from documented noncompliance. A silent period is not the same as repeated missed appointments or refusal of care.

4. Address Preexisting Conditions Directly

Review prior records when the client had earlier symptoms, treatment, imaging, surgery, disability, or restrictions involving the same condition.

Determine:

• The prior diagnosis and symptom severity
• Treatment required before the incident
• The client’s functional baseline
• Whether the condition was active, stable, or resolved
• Whether prior imaging is available
• What changed after the incident
• Whether post-incident treatment was more extensive
• Whether a provider described an aggravation or new injury

Do not omit a preexisting condition because it complicates the claim. Addressing it allows the demand to distinguish the prior baseline from the post-incident change.

Do not describe an aggravation as a wholly new condition unless the records and appropriate medical interpretation support that conclusion.

5. Match Damages to Supporting Evidence

Each damages category should connect to a record, bill, employment document, or other source.

Medical Treatment and Expenses

Confirm diagnoses, procedures, hospitalizations, surgeries, therapy, medications, assistive devices, and follow-up care. Compare treatment records with bills.

Check for duplicate charges, unrelated services, incorrect dates, missing records, and unexplained balances. A significant bill without a corresponding treatment record may draw scrutiny.

Recoverable medical expenses vary by jurisdiction, so the damages calculation should receive legal review.

Lost Income and Work Limitations

Look for restriction notes, disability certifications, reduced schedules, return-to-work dates, permanent limitations, and employer wage records.

Do not attribute lost time to the injury when the records identify another cause.

Pain and Functional Limitations

Support non-economic damages with contemporaneous evidence such as repeated symptom reports, sleep disturbance, medication use, activity restrictions, assistive devices, and interrupted work or caregiving.

Avoid relying only on labels such as “severe pain.” Identify duration, treatment, and functional effect.

6. Identify Liens and Outstanding Balances

Account for interests that may affect settlement and the client’s net recovery, including:

• Medicare or Medicaid claims
• Health plan reimbursement or subrogation claims
• ERISA plan claims
• Workers’ compensation liens
• Hospital or physician liens
• Letters of protection
• Litigation funding interests
• Unpaid provider balances

Confirm whether amounts are preliminary, disputed, negotiated, or final. A billed amount, lien amount, and recoverable medical damage are not necessarily the same.

Lien validity, priority, reimbursement, and compromise rules depend on governing law and plan terms. Obtain jurisdiction-specific legal review before making representations.

7. Verify Future Care

Future medical damages should be based on documented provider recommendations, not attorney assumption.

Look for:

• Recommended surgery
• Follow-up imaging or testing
• Specialist referrals
• Additional therapy or procedures
• Long-term medication management
• Durable medical equipment or home assistance
• Permanent restrictions
• Monitoring for complications
• A stated prognosis

Determine whether each item was discussed, formally recommended, ordered, scheduled, delayed, declined, or contingent on future symptoms.

A physician may need to clarify whether care is medically probable, optional, or unrelated to the incident. Significant claims may also require supporting cost estimates.

Findings That May Strengthen the Demand

No single finding determines value, but these may support a clearer medical narrative:

Findings That May Weaken the Demand

Identify adverse facts before the carrier does.

Do not bury adverse facts in a long chronology. Address material weaknesses directly when they affect causation, credibility, or damages.

When Physician Review Is Needed

Record sorting, extraction, and timeline preparation may not require a physician. Physician review is more important when the demand depends on clinical interpretation.

Consider physician review when:

• Causation is disputed or medically complex
• The records contain competing diagnoses
• Imaging requires interpretation beyond the report
• Significant degenerative or preexisting findings are present
• The client experienced multiple accidents or intervening events
• The mechanism and diagnosis do not clearly align
• Providers disagree about diagnosis, prognosis, restrictions, or treatment
• The claim involves aggravation of a prior condition
• Medical necessity is likely to be challenged
• Future surgery, permanent impairment, or long-term care is claimed
• The case involves medical malpractice or standard of care
• Claim value depends on a disputed medical conclusion

Give the reviewer focused questions, relevant incident facts, prior history, and the conclusions under consideration.

For a broader explanation of reviewer roles, see medical record review for attorneys.

Final Pre-Demand Checklist

Before approving the demand, confirm:

1. The provider and facility list is complete.
2. Missing records have been obtained or identified.
3. The chronology accurately reflects treatment.
4. Material histories are consistent.
5. Causation claims do not exceed the medical support.
6. Treatment gaps have been investigated.
7. Preexisting conditions are disclosed and distinguished.
8. Each damages category is documented.
9. Bills have been checked for duplication and unrelated care.
10. Wage-loss periods are supported.
11. Liens and reimbursement interests have been identified.
12. Future care is based on provider recommendations.
13. Adverse findings have been addressed.
14. Clinical questions have been escalated when necessary.
15. Diagnoses, dates, and amounts are consistent across the demand and exhibits.

Get Clinical Insight Before Sending the Demand

When a demand depends on disputed causation, complex preexisting conditions, conflicting findings, prognosis, or future care, a physician-led review can help the legal team identify what the records support and where the medical narrative requires qualification.

Learn more about Expert Institute’s Medical Record Review service.