CLAIM FOR BODILY INJURY SETTLEMENT PURPOSES ONLY

I. Medical History
Documents
1.01 Medical Office records X Reviewed X Enclosed
1.04 From Client X Reviewed X Enclosed
II. Clinical Evaluation
Documents
2.01 Physical Examination X Reviewed X Enclosed
2.02 Injuries ICD-9 codes X Reviewed X Enclosed
2.03 Symptoms documented X Reviewed X Enclosed
2.05 Special Tests X Reviewed X Enclosed
2.08 Medical Validation X Reviewed X Enclosed
From:
Claims Adjuster:
To:
Claimant:
Claim #:
Date Of Loss:
Date of this Request:
Our Demand of:
Date Response Due:
Dear XXXXX XXXXXXX,
Our firm has the pleasure of representing XXX XXXXX in connection with
the above referenced accident.
The negotiation initiated by this demand package is for a bodily injury
settlement.
Page 1
III. Diagnoses
854.0: Closed Head Injury
339.20: Posttraumatic headache, unspecified
339.21: Acute posttraumatic headache
723.8 Occipital Neuralgia
308.0: Predominant disturbance of emotions (Anxiety)
780.79: Other malaise and fatigue (Lethargy, Tiredness)
780.5: Sleep disturbance
739.1: nonallopathic lesion cervical
739.2: nonallopathic lesion thoracic
739.3: nonallopathic lesion lumbar
739.4: nonallopathic lesion sacral
739.5: nonallopathic lesion pelvic
839.01 Cervical Subluxation
839.21 Thoracic Subluxation
839.2 Lumbar Subluxation
847.0: Sprains and strains of cervical region
847.2 Lumbar Sprain
846.0 Lumbosacral Sprain
724.2 Lumbar pain/ lumbalgia
724.1 Thoracic Pain
847.1 Thoracic Sprain/Strain
724.6 Sacral pain
719.46 Leg/knee pain
720.1: Spinal enthesopathy, Disorder of peripheral ligamentous/muscular
attachme
729.99: Soft tissue disorder contusion (dense connective tissue/collagen)
920.0: Contusion of neck
922.3: Contusion of back
728.4: Laxity of Ligament abnormal L2 , L4
728.4: Laxity of Ligament C4= (5.39mm) rateable according to AMA Guides
839.08: Multiple cervical vertebrae
839.20: Lumbar vertebrae, closed
839.21: Thoracic vertebrae
840.9 Shoulder Sprain
844.9 Leg/ knee Sprain
847.3: Sprains and strains of Sacrum
723.4 Cervical Radiculopathy
924.11 Contusion Knee
decrease DTR upper ext
Client:
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III A - Radiculopathy
Diagnosis supported by symptoms that include any areas of sensory
abnormalities, numbness, paraesthesia, irregular reflexes and any muscular
weakness.
782.0 Paresthesia / tingling / burning / prickling
-- 3.22 to 3.61z gms. Diminished light touch
723.4 Cervical Radiculopathy / Radicular Syndrome - Motor and or sensory
changes
723.1 Cervicalgia - Pain in neck
III B - Spinal Compression Tests
Along with testing of sensation, strength, and reflexes, several provocative
maneuvers are useful in evaluating cervical radiculopathy. The positive
provocative orthopedic/neurologic tests are:
Cervical Distraction
Jackson Compression
Kemp's test
III D - Impairment Rating according to AMA Guides
1. Body Part or System Loss Of Motion Segment Integrity Cervical Ligament
Tear
5th Edition Chapter No. 15
Table No. 15-3a
2. Body Part or System Nerve Root Loss Of Sensation - Extremity
5th Edition Chapter No. 15
Table No. 15-15
IV. Complaints
Demonstrable and Non-demonstrable/soft tissue complaints were documented as:
Right Temporal Headache
Intensity: 4-6 Moderate
Frequency: Constant, occurring 76-100% of the day
Type: Dull
Radiation: The pain suffered by the patient is noted to radiate to the
right
Right Occipital Headache
Intensity: 4-6 Moderate
Frequency: Constant, occurring 76-100% of the day
Type: Dull
Radiation: The pain suffered by the patient is noted to radiate to the
right
Client:
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Neck pain
Intensity: 4-6 Moderate
Frequency: Constant, occurring 76-100% of the day
Type: Dull
Radiation: The pain suffered by the patient is noted to radiate to the
right
Knee
Intensity: 4-6 Moderate
Frequency: Frequent, occurring 51-75% of the day
Type: Dull
Radiation: The pain was confined to the area of complaint.
Thoracic spine pain
Intensity: 4-6 Moderate
Frequency: Constant, occurring 76-100% of the day
Type: Dull
Radiation: The pain was confined to the area of complaint.
Lumbar spine pain
Intensity: 4-6 Moderate
Frequency: Constant, occurring 76-100% of the day
Type: Dull
Radiation: The pain was confined to the area of complaint.
Pain on palpation
Intensity: 4-6 Moderate
Frequency: Constant, occurring 76-100% of the day
Type: Aching
Radiation: The pain was confined to the area of complaint.
Disturbance of skin sensation
Intensity: 4-6 Moderate
Frequency: Constant, occurring 76-100% of the day
Type: Tingling
Radiation: The pain was confined to the area of complaint.
Headaches - (post traumatic assessment)
Intensity: 4-6 Moderate
Frequency: Constant, occurring 76-100% of the day
Type: Dull
Radiation: The pain was confined to the area of complaint.
Feeling "slowed down"
Intensity: 4-6 Moderate
Frequency: Constant, occurring 76-100% of the day
Fatigue, lethargy or malaise
Intensity: 4-6 Moderate
Page 4
Client:
Frequency: Constant, occurring 76-100% of the day
Difficulty sleeping
Intensity: 4-6 Moderate
Frequency: Constant, occurring 76-100% of the day
Muscle Weakness:
Grade 3 Fair: Movement against gravity, but not against added resistance
Grade 4 Good: Movement against external resistance, but less than normal
Interference of ADL:
The determination of an impairment rating includes estimates that reflect the
severity of the medical condition and the degree to which it decreases an
individual's ability to perform common activities of daily living termed,
ADL's, that are not work related.
The patient experiences pain that interferes with activity
V. Duties Under Duress
The injured party has difficulty with Work Duties, Domestic Duties (inside
the home), Household Duties (outside the home) and Educational/studies in
School, and actually does one of the following activities while in pain and
pain interferes in these activities causing duties to be performed under
duress.
The Duties Under Duress the patient attests to experiencing during WORK
Duties are due to
Loss of promotional prospects
Difficulty in performing duties
Reduced quality of work
The Duties Under Duress the patient attests to experiencing during Domestic
Duties(Vacuuming, taking care of children, dishes, dusting, laundry,
preparing meals) are due to
Anxiety/depression
The Duties Under Duress the patient attests to experiencing during Household
Duties(Mowing/Yard work, transporting family, shopping, taking out trash) are
due to
Fatigue
Anxiety/depression
The Duties Under Duress the patient attests to experiencing during
Study/School are due to
Difficulty with postural requirements
These Duties Under Duress
are experienced daily
have been experienced since the incident
Client:
Page 5
VI. Loss of Enjoyment:
The patient attests to suffering from a Loss of Enjoyment during Domestic
activities as
Loss of entertaining
The patient attests to suffering from a Loss of Enjoyment during Household
activities as
Mowing/yard work
The patient attests to suffering from a Loss of Enjoyment during Hobbies as
socializing
These Loss of Life Enjoyment factors are
are experienced daily
have been experienced since the incident
VII. Treatment
Treatment to the patient included:
98942 Chiropractic Manipulation Treatment CMT 5
98943 Chiropractic Manipulation Treatment CMT Extra region
99204 Exam (Comprehensive)
97535 Self Care/Home Management Training (ADL's):
97110 Therapeutic Exercises
72050 X-Ray Cervical, 4-5 Views
72070 X-Ray Thoracic, 2-3 Views
72110 X-Ray Lumbar, 4-5 Views
Prescriptions:
The patient was administered a prescription for;
Anxiety Home Prescriptive Remedies.
Ice pack.
Immobilization devices.
CRMA - Computerized Radiographic Mensuration Analysis.
95851 Range of Motion Test.
Sensory Nerve Test /Monofilament Test (Dermatome).
Referrals:
The patient was referred for:
CRMA.
Fitting for brace.
Anxiety Home Prescriptive Remedies.
Medical Determination
Medical Validation (99080)
Client:
Page 6
Immobility Devices:
The patient was prescribed immobilization in the form of;
Cervical collar
Cervical pillow
Lumbar brace
VIII. Stability of Medical Condition
The patient's medical records reveal a documented showing of ongoing
complaints and treatment with progressive improvement and the time period for
stabilization ranges;
18 to 24 months
IX. Medical Determination of Future Treatment
Future treatment is definite, with a 76-100% medical certainty of
occurring.
X. Prognosis Overall
The prognosis overall is ongoing complaints with ongoing treatment
required.
The prognosis is a body part is determined stable, in that it is not
changing or fluctuating, however continued care is prescribed for that
part at stable MMI as it is medically determined that further care will
reduce future pain or prevent future incidence of worsening.
The prognosis requires the need for treatment due to neurological
findings.
The prognosis requires the need for treatment due to loss of range of
motion
The prognosis requires the need for treatment due to moderate injuries.
The prognosis requires the need for treatment due to ligamentous injuries.
The prognosis requires the need for treatment due to type and frequency of
pain.
XI. Prognosis For each body area injured:
Neck 76-100%/ Definite
Upper back 26-50%/ Possible
Mid back 26-50%/ Possible
Low back 51-75%/ Probable
Leg 51-75%/ Probable
Client:
Page 7
XII. Future Treatment Plan:
Future treatment is determined necessary when there is the presence of
moderate injuries; limitation of motion; ligamentous injury; neurological
findings and by type and frequency of pain.
According to the Croft Guidelines, this injury would fall into Grade IV:
Moderate/Severe; Limitations of motion; ligamentous instability;
neurological findings present. Fracture or disc derangement.
Grade 4 CAD Injury /future care up to107 times up to 2 years + monthly or
prn
Treatment is determined necessary due to the type & frequency of pain.
Treatment is determined necessary according to Croft Guidelines.
Treatment is determined necessary due to ligamentous injury/laxity.
Treatment is determined necessary due to limited range of motion.
Continuing treatment is necessary to those body parts that are stable.
There is a written continuing treatment plan.
Future Treatment Recommendations
Chiropractic
Medical Validation
Future expenses related to treatment
I estimate the future treatment expenses to be: Treatment is ongoing future
treatment is necessary however the extent is unknown.
Future Treatment Duration/Time
I estimate the patient will require future passive medical treatment to
continue for 2 years according to Croft Guidelines established for this grade
4 injury type
XIII. MMI For Each Body Part (max.med.improv.)
STATIC: When the MMI of a body part has been determined as static, it
indicates that the patient has stopped receiving care for the injury and that
a period of time has passed since treatment has stopped and there has been a
lack of movement or change and the condition of the injury has not improved.
The degree of capacity is static, not likely to increase in spite of
continuing medical measures. No further care is prescribed.
STABLE: When the MMI of a body part has been determined as stable, it
indicates that the patient has stopped receiving treatment for the injury and
the condition has stabilized, in that it is not changing, varying or
fluctuating. However, continued care may be prescribed at stable MMI if it is
believed that further care will reduce future pain or prevent future
incidence of worsening.
A patient may reach MMI and stop receiving treatment for one injury, however,
Client:
Page 8
other body parts that have been injured as a direct result of an accident may
continue to require either active or passive care.
The following body parts have reached MMI and are rated as:
Neck Stable
Low back Stable
XIV. % Impairment Rating
This represents a permanent medical condition resulting from accident or work
related trauma. Impairments are deviations from normal function of a body
part, organ, system or function. The presence of Impairment represents that a
function of the body part, organ, system or function can no longer be
performed normally.
The examinee must be at maximum medical improvement (MMI). The determination
of a Permanent Impairment should only be made when the injured is at a
Permanent and Stationary condition (P&S), and it has been determined that the
examinee is stable, and that no further restoration of function is probable.
The percentage of impairment in this patient is as follows:
Spine % Impairment 29 %
Cervical Diagnostic Related Estimate
DRE Category 4: 25-28% Impairment - Loss of motion segment integrity,
bilateral or multi-level radiculopathy, compression fracture greater than
50%, developmental fusion.
Lumbar Diagnostic Related Estimate
DRE Category 2: 5-8% Impairment - Findings of muscle spasm, non-verifiable
root pain, history of radiculopathy with a positive imaging study,
resolved without surgery.
XV: % Whole Body Impairment (WPI)
Total % Whole Body Impairment: 29%
The medical impairment has had an impact on the client's Activities of
Daily Living, Duties Under Duress (DUD - disability) and Loss Of Enjoyment
(LOE).
As a result of the impairment, there are preclusions from duties under
duress and losses of life's enjoyment as continued within this report.
The degree of impairment is not likely to change by more than 3% within
the next year.
Client:
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XV. LIABILITY
As referenced by the enclosed accident report, liability is clear. But for
your insured's failure to obey the stop sign the collision would not have
occurred.
After investigating the accident, the investigating officer found that your
insured was at fault for the collision.
Pursuant to the enclosed accident report, the driver of your insured"s
vehicle was at fault for this accident.
Also, as indicated on the accident report, the investigating officer
concluded that my client did not contribute to the accident and thus was
not negligent.
We are solely addressing the issue of the damages for which your insured
is responsible.
XVI. Current Expenses/Losses
XVII. Mileage Costs
Mileage driver costs are allocated to the total number of miles the client
has been required to drive in order to meet all appointment"s and
requirements as directly related to and necessary as a result of the
aforementioned accident and injuries as allowed by statute.
Miles driven to/from:
XVIII. Future Medical Costs
The Doctor estimates the patient will be required to be seen for a total of
36 visits. The Doctor estimates the charges for the primary treatment to be $
The Doctor estimates that future medical expenses for Labs, Diagnostics,
It is determined that future treatments are recommended when there is a 51%
or greater chance of medically probable clinical occurrence.
Client:
Current Treatment Expenses: XXXX.XX
Total Current Medical Costs: XXXX.XX
Radiographs, MRI's, CRMA and other medical expenses will be a total of: XXXX.
The Doctor estimates the total cost of future treatment to be: XXXX.
Page 10
95 per visit for a total of $ XXXX.
XIX. Evidentiary Conclusion
The medical condition has had an impact on the client's Duties Under
Duress (DUD - disability), Loss Of Enjoyment (LOE) and Activities of Daily
Living.
There is the presence of losses of specific capacities of this individual
to meet demands as contained within the reports.
There is cause to believe that the client is likely to suffer from injury,
harm or further impairment by engaging in activities of daily living,
duties under duress or suffer loss of enjoyment of activities necessary to
meet personal, social or occupational demands.
The degree of capacity is static, not likely to increase in spite of
continuing medical measures.
XX. DEMAND FOR SETTLEMENT
Based upon the liability, impact, well documented objective medical findings
inclusive of; Injuries, Diagnoses, Complaints by; intensity, frequency, type,
radiation and further effects on the individual including the documented
permanent impact and effect upon my clients Loss of Enjoyment of Life, Duties
under Duress, and given consideration to the treatment, plan, prescriptive
recommendations, stability of the medical condition, prognosis, future
treatment, current and future medical costs, economic losses, MMI, percentage
of whole person impairment and total monetary factors, please indicate your
Upon receipt of your offer to tender, I will review your offer with my
client.
Our law firm tax identification number is (___).
Page 11
Client:
settlement check made payable to XXXX@XXXX.XXX, on or before XX/XX/XXXX.
willingness to offer to tender $XX,XXX.XX by forwarding a release and