Learn what a “causal relationship” means for your workers’ comp case. Prove your injury was work-related to get the payout you deserve.
Employers are obligated to provide their employees with a safe and healthy work environment.
Most also have to provide their workers with workers’ compensation insurance. This insurance pays medical bills and wage benefits for workers injured on the job.
You won’t qualify for workers’ comp unless you can show a causal relationship between your job and your work accident. This relationship means that you suffered your work injury while in the scope of your employment or while performing duties related to your job.
You can likely prove this using evidence like medical reports and witness statements. If an employer or its insurance company denies your benefits because of a lack of a causal relationship, you can appeal that decision with your state’s Workers’ Compensation Commission.
“Causal Relationship” in Workers’ Comp Cases
Workers’ compensation is a no-fault insurance program. No-fault means that you don’t have to prove that an employer or a co-worker caused or contributed to your injury in any way.
But people injured on the job do have to prove that:
- They were injured
- They notified their employer of the injury
- There is a causal relationship between their job and the injury or occupational disease
“Causal relationship” essentially means that an injury happened because of your work. Since workers’ compensation pays you benefits for work-related injuries, it follows that you have to prove your injuries were work-related to receive compensation.
You’ll have to show a causal relationship between your employment and injury after filing a workers’ compensation claim with your employer’s insurer.
In many cases, workers can prove work-relatedness fairly easily. For example, if you’re working and people see you hurt your back while lifting a heavy object, you have witnesses of your accident and you can reference the heavy object.
However, not every workers’ compensation case runs this smoothly. Consider a scenario where a data entry worker develops carpal tunnel syndrome. The worker may try to file a workers’ comp claim saying the injury is caused by workplace typing and data entry. But if the same worker enjoys playing the piano or knitting, then a causal relationship may be more difficult to prove.
Keep in mind that if you file a workers’ comp claim, either your employer or its insurance company can say that your work duties were not the real cause of your injury, resulting in a denial of your claim. Read this case example of an employer wrongly denying workers’ comp, arguing the employee was technically volunteering at the time of the injury.
A pre-existing condition is a medical condition that started before you suffered a work injury. An employer or insurer can sometimes point to a prior injury to show that there is no causal connection between an injured worker’s job and their present injury.
For example, maybe you were very active in sports while growing up and suffer from bad or weak ankles. If you then sprain or twist your ankle at work, the insurance company could say that any pain or discomfort you experience is due to your pre-existing ankle issues.
Most states say that a worker with a pre-existing condition can receive workers’ compensation benefits if a work accident aggravated or worsened the pre-existing condition, either temporarily or permanently.
A workers’ comp claimant can usually prove aggravation by showing that they suffered new symptoms from the work accident long after the original injury.
Case Summary: Work Injury with a Pre-existing Condition
Sharon Mangiaracina was working for Avis Budget Group in January of 2013. She injured her shoulder, back, and thumb during work when her office chair fell forward.
Ms. Mangiaracina had a pre-existing injury to her left shoulder. She was receiving medical treatment for the condition at the time of her work accident. When she filed for workers’ comp, an adjuster for Avis’ insurance company denied all benefits based on the pre-existing condition.
Ms. Mangiaracina appealed that decision, and her state’s Office of Workers’ Compensation ruled in her favor.
The office awarded her temporary total disability benefits after it found:
- The claimant suffered a work-related injury
- Her pre-existing injury was aggravated by the work accident
Avis appealed those findings and maintained that there was no aggravation. Ms. Mangiaracina eventually won on appeal, based on Louisiana’s workers’ compensation laws.
The law presumes a workplace injury aggravates a prior condition if the worker proves:
- They didn’t suffer any disabling symptoms before the accident
- The disabling symptoms appeared after the accident
- Medical evidence demonstrates a possibility that the work accident caused the new symptoms
The court reasoned that the above were met since:
- Ms. Mangiaracina testified that her pre-existing shoulder condition did not limit her work
- After the accident, her doctor ordered her to limit her activities and not place stress on her shoulder
- Medical reports showed that the work incident caused new trauma to Ms. Mangiaracina’s shoulder
Proving a Causal Relationship for Work Injuries
Injured workers have the burden of proof when it comes to showing that an injury resulted from their employment.
Depending on the facts of your case, you can likely meet this burden by explaining the facts of your accident to the insurance adjuster handling your workers’ comp claim. If your accident took place at work and you immediately suffered an injury, the insurance company will typically agree that your injury is, in fact, work-related.
In harder cases where there is a question of whether your injury was work-related, you can most often prove a causal relationship with a medical report. The report should come from your treating physician and say that the proximate cause of your injury was some work duty or task.
Medical reports that show a causal connection often:
- Contain a complete and accurate account of your medical history
- Set forth well-reasoned opinions
- Include the doctor’s credentials, which help support the accuracy of the physician’s medical opinion
- Refer to the facts of your injury and use them to help place your work accident at the scene of your employment
You can’t establish causation through a simple physician’s opinion unless the doctor backs it up in detail.
Reasonable Medical Certainty
State laws usually say that a casual relationship will only exist if a doctor can explain causation with “reasonable medical certainty.” This phrase does not mean absolute certainty. A report will succeed by explaining that a job task or duty caused your injury to a reasonable degree of medical certainty.
If you suffer from a pre-existing condition, your doctor will have to explain that your work accident resulted in the aggravation of your prior condition. Again, this explanation must occur with reasonable medical certainty.
Worker’s Comp Commission Hearing to Prove Causation
If you’re denied workers comp benefits on the grounds that your employer or its insurer believes your work accident wasn’t related to your job, you have the right to appeal that decision.
If you do, then in most cases you’ll have to prove your case to your state’s Workers’ Compensation Commission. This is most often done during a court hearing.
You do have the right to consult with a lawyer before this hearing or hire an attorney to represent you at the hearing. During the event, you or your attorney will have to present evidence that there’s a causal relationship between your employment duties and your work injury.
A Workers Compensation Commission can consider any factual evidence to help it decide whether a causal relationship exists.
Most lawyers present three types of evidence:
- Medical records and reports from your healthcare or medical care providers
- Your testimony regarding your work accident and the treatment you received
- Testimony or statements from people that witnessed your accident
Burden of Proof
Again, you have the burden of proving that your work injury was work-related. In the course of a case before a state’s Workers’ Compensation Commission, the standard of proof is often referred to as a “preponderance of the evidence” standard.
Under this standard, you’ll succeed in your case if you can prove that your work accident more likely than not caused your injury. Put another way, you’ll win your case by showing that there’s a 50.1 percent likelihood that your work event caused your injuries or illness.
As with medical opinions from doctors, you do not have to demonstrate with absolute certainty that a work incident resulted in your personal injury.
If a Commission does find a causal relationship, an appeals court can’t reverse that decision. This is true provided that you presented credible evidence of such a relationship or if the Commission could draw reasonable inferences of a relationship from your evidence.
Common Ways an Insurer Will Deny Causation
Employers and their insurers don’t challenge a causal relationship in every workers’ compensation case. These cases are most commonly challenged if the employer or insurer doesn’t believe your injury is work-related, or blames your problems on a pre-existing condition.
1. A Faulty or Weak Medical Report
Insurance adjusters will often challenge or deny causation when your doctor provides a medical report with little evidence that your injury was suffered at work.
For example, an adjuster may say that a medical report is:
- Speculative and not based on concrete facts
- From a medical provider will little experience treating your specific injuries
- From a treatment provider that is not familiar with workplace injuries
- Lacking important information regarding your medical history
If you can meet or speak with your doctor before they write a medical report, the physician can usually write a better report.
Tips for helping your medical provider write a more effective report:
- Discuss the reasoning for the report and who you’ll provide it to
- Give the doctor a detailed factual account of your accident
- Inform your physician of any pre-existing conditions or any treatment you received to the injured part of your body
- Provide your doctor with a description of your employment and work duties
- Ask the physician if they can include within the report that they are giving their opinion to a reasonable degree of certainty
2. No Evidence to Show a Causal Relationship
Insurance companies often challenge causation when no one saw the work accident. With no witnesses of the event, they can call the entire accident into question.
If this is true, make sure to provide the insurer with your own statement of how your incident took place. Provide as many facts as possible.
It’s also a good idea to check to see if your employer has any surveillance video of the accident. Sometimes even a small amount of corroborating evidence will go a long way in supporting a workers’ compensation claim.
Get Help From a Workers’ Comp Attorney
If it’s obvious that your job caused your work injury, you probably won’t need to speak with a workers’ compensation lawyer to file a claim. Just make sure you promptly notify your employer of your accident and submit all the necessary workers’ comp forms.
If your employer questions whether your injuries occurred in the course of employment, your claim is denied, or you’re the subject of a workers’ comp investigation, contact an attorney to discuss your injury case.
A skilled lawyer can advise you of your state’s applicable workers’ compensation laws and how they impact your case.
An attorney can also help you gather important evidence to help show a causal relationship. This evidence includes a thorough medical report that provides a causal connection between your work tasks and your injury.
Most workers’ compensation law firms provide new clients with free consultations. A free consultation means you can get your questions answered without spending a dime.
Don’t let your employer or its insurer deny what’s rightfully yours. Talk to a lawyer to get the workers’ compensation benefits that you deserve.
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