How to Handle Pre-existing Conditions in Workers' Compensation Claims



In most states, an injured worker is eligible for workers' compensation benefits if his on-the-job injury is an aggravation of a prior injury or condition (both are called pre-existing conditions). A worker is not eligible for workers' comp benefits if the only injury is the pre-existing one; he must have sustained a new injury.

Pre-existing injuries can include herniated disks, broken bones, torn ligaments, and other relatively obvious injuries. Other conditions may be more closely related to general physical health, such as age-related spine degeneration or arthritis.

It's not uncommon for an insurance company to wrongfully deny a legitimate claim because of a pre-existing medical condition. Many times, an injured worker simply gives up on the claim; however, insurance companies cannot immediately deny an on-the-job injury claim based solely on a pre-existing condition.

The rationale supporting giving workers' comp benefits for the aggravation of a pre-existing condition follows the "but for" rule often quoted by lawyers.

Example: Back Injury Caused by Lifting Boxes

A worker is loading boxes onto his delivery van when his pre-existing back injury flares up. He didn't have any problems with his back when he woke up that morning. In fact, he's been fine since he recovered from his prior injury two years ago. Therefore, the act of loading the boxes is the cause of the worker's pain and discomfort, not the prior back injury.

"But for" the loading of the boxes, the pre-existing back injury would not have manifested itself. Performance of the worker's duties loading boxes onto the van is the sole cause of his new injury.

In most states, employers hire employees "as is." When you buy a used car and the sign on the window says, "Sold As Is," that means you are responsible to pay for any repairs it might need. While human beings aren't cars, the "as is" principle is similar.

Payment of Medical Bills and Lost Wages

Whether your current workers' comp claim is based on a re-injury, or aggravation of a medical condition sustained on a previous job, you're entitled to have all necessary medical bills paid and the same percentage of lost wages as anyone else injured on the job.

This is true whether your old injury was fully healed or not, and as long as you didn't perform actions restricted by your doctor. Ignoring your doctor's orders might be grounds for a rightful denial of your new injury claim.

Example: Mechanic Re-injures Leg

A mechanic working for a car dealership is injured when a portable hydraulic lift loses power. The front wheel of a car falls on his leg and fractures his tibia. He files a workers' compensation claim and receives full medical and lost wage benefits. In a few months, the mechanic reaches a level of maximum medical improvement (MMI). His doctor clears him to return to work full time and resume his previous job duties.

A year later, the mechanic resigns from his position and accepts a new job at another car dealership. While working at the new dealership, he falls and re-fractures his tibia. The new employer's workers' comp insurance should pay all his reasonably necessary medical bills and lost wages.

Example: Mechanic Ignores Doctor's Orders

Another mechanic at a different dealership sustains a broken tibia in the same type of accident; however, his doctor instructs him not to resume or accept any job duties where undue pressure might be exerted on his injured leg. The doctor specifically tells him not to work with hydraulic jacks because using them requires leg strength.

Several weeks later, he interviews for a job with a new dealership. The pay is higher, but the job duties include working with a hydraulic jack. He accepts the job anyway. One day the hydraulic jack he's operating begins to slip. He uses his leg strength to prevent it from falling, and the pressure causes his previously injured tibia to fracture.

The mechanic files a workers' comp claim. After reviewing the medical records from his previous job injury, the insurance company justifiably denies his claim because he ignored his doctor's orders.

A few states make a further distinction regarding prior injuries as they affect workers compensation benefits. In these states, if the pre-existing medical condition was from a non-work-related injury, the worker is not eligible for benefits.

Building an Effective Claim

Workers' compensation laws were enacted to make the employer-worker injury claim process less adversarial. Over time, insurance companies responsible for compensating injured workers became huge corporations with stockholders to answer to, profit margins to meet, and executive salaries to pay. As a result, the once non-adversarial system has become more adversarial than ever.

Insurance companies look for any means to deny your injury claim. The insurance adjuster assigned to your claim will thoroughly investigate your medical background and look for any evidence of falsehoods concerning pre-existing conditions.

Trying to be greedy in a claim ultimately backfires. It's better to tell the truth. If questions on the doctor's admitting form ask if you have any pre-existing medical conditions, you must answer truthfully. If the medical staff or doctors ask you, you must be honest with them. Failing to disclose a pre-existing condition can be grounds for denial of your claim.

Be clear when discussing your current pain and discomfort with the doctors that it's very different from any residual pain and discomfort you may have from a pre-existing injury. Let them know you did not have symptoms before your current injury. If you tell the doctors your current symptoms are no different than those you've been experiencing since your previous injury, your claim will likely be denied.

Giving detailed information during your medical exams is very important. Clearly explain that you weren't having pain or discomfort from a prior injury when your new injury occurred. Describe any changes in the type of pain you're feeling, including its frequency, intensity and duration. Tell the doctor how the new injury is affecting your daily activities in a way it hasn't since your prior injury.

You want to place as much distance as possible between your prior condition and the new on-the-job injury. The greater the percentage of pain, discomfort, and disability from your new injury, the less your claim will be reduced as a result of your pre-existing condition.

During the investigation of your claim, you may be diagnosed by two or even three doctors, and you may have to undergo an independent medical examination (IME). Always give them the same detailed information about your symptoms, level of pain, and disability. Consistently reporting your condition greatly improves the chances of reaching a consensus among all the doctors.

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