The cover letter you send with a case is the most controllable factor in the quality of the opinion you get back. The doctor's expertise, the exam, the records — those matter, but you don't write them. You write the letter. A clear, organized, factual letter gives the expert everything they need to address the actual issues in dispute. A vague one produces a vague report, and you usually find out after the exam, when it's expensive and slow to fix.

Here’s what belongs in it to make sure the expert understands the assignment, the relevant facts, the materials provided, and the specific opinions you need.

1. The introduction

Clearly identify the matter and provide all administrative information necessary for the expert to understand the case context: claimant information (name, date of birth, date of loss); requesting party (attorney or representative, party represented); and examination details (date, time, and location of exam as well as if an interpreter, observer, and/or videographer will be present)

2. The purpose of the examination

Clearly explain why the assessment is being requested and what issues the expert is being asked to address: referral reason (nature of dispute, purpose of evaluation) and scope of evaluation (diagnosis, causation, reasonableness and necessity of treatment, Maximum Medical Improvement, prognosis).

3. The case background

Provide a concise, objective summary of the case with sufficient factual context around claimed injuries (body parts or conditions at issue, alleged diagnoses, and current complaints).

4. The documents for review

Provide a list or index of the records provided to ensure completeness of the expert’s opinion: medical records (primary care, hospital), specialist records (treating physician reports, independent expert reports), diagnostic testing (MRI/CT reports and images, X-rays), employment and disability records (job descriptions, disability applications, functional capacity evaluations), and litigation materials (depositions, witness statements, accident reports, interrogatories and pleadings). This ensures your expert can include a comprehensive list in their report.

5. The questions for opinion

Provide a list of questions that should be answered and are clear, objective, medically relevant, and tailored to the issues in dispute. Here is a starter set that you can adapt to the case:

1. What are the claimant's current diagnoses?

2. Are the claimant's subjective complaints supported by objective findings?

3. Are the diagnosed conditions causally related to the reported incident?

4. To what extent do pre-existing conditions contribute to the claimant's current presentation?

5. Are there alternative explanations for the claimant's symptoms or findings?

6. Was treatment rendered to date medically reasonable and necessary?

7. Has the claimant reached Maximum Medical Improvement (MMI)? If not, when is MMI reasonably anticipated?

8. Is there permanent impairment?

9. What restrictions or limitations currently exist? What long-term limitations, if any, are expected?

10. What is the claimant's expected prognosis?

11. What future treatment is anticipated?

12. Are there inconsistencies between the claimant's reported symptoms and objective findings?

13. Are there inconsistencies within the medical records?

14. Based on your opinion, has the billing been appropriate? 

The wrap up

Hear directly from Dr. David Feiner, our Founding Medical Adviser - including how a recent cover letter helped him write a better, more impactful report:

The quality of the report starts with the quality of the instructions; CaseLynx has already built this into the process of every case that we coordinate and is always here to help.This article is for informational purposes only and does not constitute legal advice.