Medical Record Gaps: How Inconsistent Treatment Documentation Undermines West Virginia Injury Claims

The moments following an accident are a chaotic mix of adrenaline, pain, and confusion. Your first instinct is to get immediate medical attention for your most obvious injuries. After a visit to the emergency room or an urgent care clinic, you might feel that the worst is over. As days turn into weeks, however, a nagging pain might persist or even worsen. Many people in this situation try to “tough it out,” hoping the problem will resolve on its own. They delay follow-up appointments, put off physical therapy, or hesitate to fill prescriptions, often due to cost, work schedules, or simply underestimating the severity of their injury.

This common scenario creates a serious but often overlooked problem in a personal injury claim: a gap in medical treatment.

What Exactly Constitutes a “Gap” in Medical Records?

A “gap” in medical treatment is any significant period during which you are not receiving medical care for injuries related to your accident. Insurance adjusters are trained to scrutinize your medical timeline with a fine-toothed comb, looking for any inconsistencies that they can exploit. These gaps are red flags that they believe suggest your injuries are not as severe or as causally related to the accident as you claim.

These damaging gaps can appear in several forms:

• Delay in Seeking Initial Treatment: Waiting several days or weeks after an accident to see a doctor is one of the most significant red flags for an insurer. Their immediate argument will be that if you were truly hurt, you would have sought care right away.
• Long Breaks Between Appointments: If your doctor recommends follow-up visits and you wait months to schedule them, it creates a questionable void in your record. The insurer will argue that an unrelated event could have occurred during this time to cause your current pain.
• Failure to Follow a Treatment Plan: Discontinuing physical therapy before you are medically released, not filling prescribed medications, or failing to see a recommended specialist can be interpreted as a lack of commitment to your own recovery.
• Stopping Treatment Prematurely: Deciding you feel “good enough” and ceasing all medical care, only to have the pain return with a vengeance months later, creates a narrative that the insurance company will use against you.

Why Do Gaps in Treatment Happen? Legitimate Reasons vs. Insurer Interpretations

Most people do not stop medical treatment because their injuries have magically healed. The reality is that life gets in the way. There are countless valid, real-world reasons why a person might have a gap in their medical care.

Some common and perfectly legitimate reasons include:

• Financial Hardship: The cost of co-pays, deductibles, and prescription medications can be overwhelming, especially when you are out of work due to your injuries.
• Scheduling Conflicts: Juggling medical appointments with work responsibilities, family obligations, and childcare can be incredibly difficult.
• Transportation Issues: If your vehicle was totaled in the accident, simply getting to and from appointments can be a major logistical challenge.
• Temporary Improvement: It is common for some injuries, like soft tissue damage, to feel better for a period before the pain and stiffness return. A person might honestly believe they are recovering and no longer need care.
• Delayed Onset of Symptoms: Some serious injuries, particularly those involving the spine or brain, do not manifest their full range of symptoms immediately after a traumatic event.

Unfortunately, an insurance adjuster, whose job is to protect their company’s bottom line, will not view these reasons with empathy. They will interpret the gap in the light most favorable to them, which is almost always detrimental to your claim.

How Insurance Adjusters Exploit Inconsistent Treatment Histories

When an insurance adjuster sees a gap in your medical records, they do not see a person struggling with logistical or financial burdens. They see an opportunity. They will use the gap to build a case against you, often relying on one or more of the following arguments to devalue or deny your claim.

• Argument 1: The Initial Injury Was Not Serious. The adjuster will contend that if the accident had truly caused a significant injury, you would not have been able to tolerate a break in treatment. They will use the gap as “proof” that your pain level was minor and that your current complaints are an exaggeration.
• Argument 2: A New, Intervening Event Caused the Injury. This is one of the most common and effective tactics. If there is a month-long gap in your treatment, the insurer will argue that you must have re-injured yourself in some other way during that time—perhaps by lifting something heavy, playing a sport, or even just slipping at home. They will claim this new event, not the original accident, is the true cause of your current medical problems.
• Argument 3: The Claimant is Not a Credible Plaintiff. By failing to follow through with prescribed care, the adjuster will paint a picture of you as someone who is not diligent. They will suggest that if you were not committed to your own recovery, you cannot be trusted to provide an accurate account of your pain and limitations.
• Argument 4: The Treatment Was Not Medically Necessary. If you stop treatment and then restart it later, the insurer may refuse to pay for the later treatment. They will argue that since you were able to function without it for a period, it must not have been essential for your recovery from the accident.

The Legal Challenge: Proving Causation in West Virginia

In any West Virginia personal injury case, the burden of proof rests on the injured party. You must demonstrate, by a preponderance of the evidence, that the other party’s negligence was the direct and proximate cause of your injuries and subsequent damages. A complete, uninterrupted medical record creates a clear, straight line connecting the accident to the injury and all the treatment that followed.

A gap in treatment breaks this line. It creates a period of uncertainty that the defense will exploit. They will argue that the chain of causation is broken and that it is impossible to say with legal certainty that the treatment you received after the gap was necessitated by the original accident. This can make it significantly more difficult for your attorney to prove your case in court.

The Impact of Gaps on Different Types of Damages

The value of a personal injury claim is determined by calculating various categories of damages. Gaps in your medical history can negatively affect the valuation of each of these categories.

• Economic Damages: These are your calculable financial losses. When there are gaps in your treatment, an insurer is more likely to dispute the necessity of future medical expenses. They may refuse to cover the costs of a recommended surgery or long-term physical therapy, arguing that your break in care shows it is not really needed. They can also use it to challenge your claim for lost wages, suggesting you could have returned to work sooner.
• Non-Economic Damages: These damages compensate you for intangible losses like physical pain, emotional distress, and loss of enjoyment of life. This part of your claim is heavily reliant on your medical records and your personal testimony. A gap in treatment gives the insurance company a powerful tool to argue that your pain and suffering could not have been that severe. They will ask a jury, “If the claimant was in as much pain as they say, why did they wait six weeks to see their doctor again?” This can severely undermine your credibility and reduce the perceived value of your suffering.

Pre-Existing Conditions and the “Thin Skull” Rule

Insurance companies are notorious for trying to blame an injury on a pre-existing condition. If you had a bad back years ago, they will argue your current back pain is just a flare-up of the old issue, not a result of the recent car accident. A gap in treatment makes this argument much stronger. The defense will suggest the gap represents a period where your old condition was dormant, and some other event caused its return.

West Virginia law follows a principle known as the “eggshell plaintiff” or “thin skull” rule. This rule states that a negligent defendant must take their victim as they find them. If a person is more susceptible to injury because of a pre-existing condition, the at-fault party is still responsible for the full extent of the harm they caused, even if a healthier person would not have been injured as badly. However, a gap in your treatment record gives the defense a foothold to argue that the harm was caused by the pre-existing condition alone, not an aggravation of it from the accident. Proving the connection becomes much more difficult.

What Can You Do to Mitigate the Damage of Treatment Gaps?

If you already have a gap in your treatment, all is not lost. However, it is important to take immediate and decisive steps to counteract the negative inferences the insurance company will try to draw. A proactive approach can help repair the narrative of your recovery.

• Resume Treatment Immediately: The most important step is to get back on track with your medical care. Do not delay any longer.
• Be Honest with Your Doctor: When you resume treatment, explain to your physician precisely why there was a gap. Note if it was due to finances, transportation, or because you temporarily felt better. Ask them to document this reason in your medical chart. A doctor’s note explaining the gap is far more credible than your own explanation later on.
• Keep a Detailed Pain and Symptom Journal: Meticulously document your daily pain levels, physical limitations, and how the injuries are affecting your life. This continuous record can help fill the narrative void left by the lack of medical records.
• Preserve All Related Documents: Keep records that can help explain a gap. This could include emails with your boss about scheduling difficulties, financial statements showing hardship, or even car repair bills that demonstrate a lack of transportation.
• Stay Off Social Media: Never post anything about your accident, injuries, or daily activities online. An insurance investigator will be looking for photos or posts that contradict your injury claims, such as pictures of you engaging in physical activity, which they will use to compound the damage of a treatment gap.
• Consult with an Experienced Attorney: The sooner you involve a lawyer, the better. An attorney can provide guidance on how to manage your medical care and communications to protect the value of your claim.

Experienced Legal Advocacy for Your West Virginia Personal Injury Claim

The path to recovery after an injury is physical, emotional, and financial. The integrity of your medical record is a foundational piece of that financial recovery. A gap in treatment can feel like a weakness in your case, but it does not have to be a fatal flaw.

The legal team at Powell & Majestro, P.L.L.C., has substantial experience in personal injury law, assisting individuals and families throughout West Virginia who have been harmed by the negligence of others. We know how to build a strong, evidence-based case that anticipates and overcomes the tactics used by insurance companies. We are dedicated to pursuing the full and fair compensation you deserve.

If you have been injured and are concerned about how your treatment history might affect your claim, we invite you to contact us. For a free, no-obligation consultation to learn more about your legal options, call our office today at (304) 346-2889 or reach out to us through our online contact form.