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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Visitor Questions on Issues with Work Injury Claims
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I fell originally on 12/31/2015 at work and ended up having rotator cuff surgery. I settled on this claim but then on 1/10/17 I fell again outside of work on ice. I fell on the same arm and the diagnosis was a strain. I was sore so I went back to the surgeon who did... Read More.
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I was diagnosed with colon cancer. I was denied long term disability insurance after my short term insurance ran out. They stated it was a pre-existing condition, even though it had not been diagnosed. I am now cancer free as the result of surgery. I had an ileostomy that has now been reversed, but the... Read More.
I’ve had back pain for years. I finally got insurance and was seeing my family doctor. She agreed to send me to a pain management doctor, who is also a back specialist. I saw him and he had 2 MRIs done on me, one with contrast and the other was just plain. He also took... Read More.
I fell at work 4 months ago and hurt a pre-existing lower back injury, plus causing new injuries in my neck, upper back and hip. Today I fell while still out on workers’ comp, due to my back locking and having spasms. My leg is still weak so I could not get my footing and... Read More.
I injured my left knee last year at work. I had a torn lateral meniscus and that was shaved off. I’ve been doing good the last 6 months or so. Now all of a sudden, my knee is starting to give out and I can’t bear weight on it. Would this still be covered by... Read More.
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Let’s say you work for a company and get hurt. The employer does not carry workers compensation insurance, but still pays for the treatment. If you no longer work for that company, are they still responsible for upkeep if you re-injure it in the future? What if the previous injury resurfaces on its own? Is... Read More.
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I have 2 jobs, one full-time and one part-time. I fell at work at the part-time job. I broke my pinky finger and injured my ring finger in the fall. I’ve had 3 surgeries on the pinky and might face a joint replacement or infusion. Workmans comp says Maryland is not a “double stack” state... Read More.
I worked for a cola company for 36 years. I am 61 years old and have had three previous back surgeries due to my job (the last surgery was in 2012). I returned to work until Feb 2013 at which time my back again had problems. Workers comp sent me to two doctors, both of... Read More.
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I injured my back after lifting roof decking while at work. I reported it to my supervisor that same day and continued to work. After several days the pain in my back and left leg was getting so bad I had a hard time walking. At that point I took a voluntary day off as... Read More.
I was walking at work and due to my employer’s policy of wearing heals I tore up my knee and tore my leg muscle. While off due to that injury I went to do my physical therapy at home and tore my PCL in my other leg. Would this be considered part of my first... Read More.
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I slipped off a company van and sprained my hand. I did not know I had osteoarthritis in that hand. Ever since the fall my finger and hand stay swollen and it’s very painful. I have cream to rub on my hand given to me by my workmans comp doctor, and I take celebrex which... Read More.
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I was at work, doing a typical job task on my knees stocking cameras. Upon getting up, I had an intense pain, pull and pop in my knee. The doctor says X-rays show a break or fracture of the bone behind the knee. Workers Compensation Claims Management says it isn’t a typical injury and it... Read More.
I was at work lifting two different die sections, moving them from one cart to another cart. While setting the second die section down I felt excruciating pain in my lower back and right butt. I now have the L5 disc herniated which will need surgery. In the past I had problems with the same... Read More.
I was injured in the past on my job and settled with workers compensation. I recently had another injury (a slip and fall) and am out of work once more. I talked with one lawyer about my case, but they did not call back. Do you think the lawyer could be hesitant to take the... Read More.
While caring for a patient I tripped over the patient’s wheelchair wheel and twisted my left knee. The employer’s insurance company has denied me benefits due to a pre-existing arthritis condition. I did not know about this condition. I had no problems with my knees until after I twisted my left knee. There wasn’t anything... Read More.
I have a few workers comp questions that I hope you can help me with. I work on computer keyboards for 8 hours everyday, non-stop. The pay is based on occupancy rate. Anyway, I started to lose strength in my hand, then numbness set in, then tingling in my pinkie and ring finger. After that... Read More.
My friend fell at work a few years ago, went out on workers comp for a few weeks, after a few injections went back to work full duty and the case was closed. A few days ago he fell again on ice and his back hurts in the same exact spot it hurt before but... Read More.
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My husband was injured at his place of employment in February of this year. He was out of work from February ’till May of this year. His doctor didn’t want him to go back to work, but he has worked all his life and convinced the doctor to release him. Prior to him returning to... Read More.