You may be entitled to workers’ compensation benefits when a workplace injury aggravates a pre-existing condition. Here’s what the insurance company won’t tell you.
Workers’ compensation insurance companies are quick to flatly deny workplace accident claims made by employees who have old workers’ comp injuries, unrelated prior injuries, or age-related health conditions.
But most states’ workers’ compensation law says injured employees are eligible for workers’ comp benefits even when their work injury is a worsening of a pre-existing injury or condition.
Protect your right to fair workers’ compensation. Learn how to separate your new work injury pain and symptoms from prior injuries to the same body part. Be aware of what to say to your treating physician and any worker’s compensation or IME doctors.
Build a Strong Claim for Aggravation of a Pre-Existing Condition
Insurance companies look for any reason to deny your injury claim. The insurance adjuster assigned to your claim will thoroughly investigate your medical background and look for any evidence of pre-existing conditions.
Build your workers’ comp claim with that in mind.
1. File your workers’ comp claim right away
Don’t wait to see if the pain eases up, or for your supervisor to tell you to file a claim. Report the injury to your employer and file a workers’ compensation claim as soon as possible after an injury.
2. Never try to hide your pre-existing condition
Neglecting to disclose a pre-existing condition can be grounds for denial of your claim.
On the other hand, don’t make excuses for your symptoms. If you immediately felt a sharp pain in your back after lifting a case of copier paper, don’t remark to the doctor, “I guess back troubles are to be expected at my age.”
3. Be detailed and specific
When you make your claim, write down exactly what happened. Be specific about the pain you felt, and how the work incident gave you pain unlike any you’ve ever had before.
4. Seek prompt medical care
Repeat those same details at every medical exam, and to every new medical provider, you may see. You must consistently make it clear that you would not be having your current pain and limitations but for the injury you suffered at work.
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.
Separating New Work Injuries from Pre-Existing Conditions
You want to place as much distance as possible between your prior medical condition and the new on-the-job injury.
The greater the percentage of pain, discomfort, and disability from your new injury, the less chance your claim will be reduced as a result of your pre-existing condition.
When discussing your current pain and discomfort with the doctors, be clear that it’s very different from any residual pain and discomfort you may have from a pre-existing injury. Let them know you didn’t have those 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.
Be Ready for Worker’s Comp Claim Challenges
Most working adults have been around long enough to have had some kind of physical injury during their lifetime. The insurance company will take a hard look at your entire medical history with three questions in mind to challenge the validity of your claim.
Did the pre-existing condition cause the injury?
Back injuries are one of the most common reasons for workers’ compensation claims. If a construction worker blew out his back while lifting bags of concrete mix on the job, he’ll likely be eligible for workers’ compensation. But suppose that same worker had knee injuries years before due to an ATV wreck.
The insurance company will want to know if the two injuries are related. If the worker never had any trouble with his knee, probably not. But if his knee gave out while he was lifting, causing him to twist his back, it’s a different story.
The insurance company will fight to prove the employer is not responsible for the worker’s injured back.
When and how did the pre-existing condition develop?
This time let’s say the injured construction worker’s only pre-existing condition was wear and tear on his back from years of heavy lifting and hard work. Until he blew out his back lifting those bags of concrete mix, he never knew his spine was degenerating.
If the injured worker hadn’t been with this company for very long, the insurance company will jump at the chance to say the worker’s back injury was caused by previous employment.
It will be up to the worker’s doctors and lawyer to prove the worker wouldn’t be disabled with pain but for his lifting bags of concrete mix that day while performing his job duties.
Is this a pre-existing workers’ comp claim?
Workers’ compensation claims for new injuries can be very difficult to win if the worker has previously been paid by workers’ comp for a similar injury, even if the old claim was with a different employer.
All the records from the old claim are fair game for the insurance company. The challenge for the injured worker will be to prove the old injury was completely resolved and unrelated to the current injury.
You’re Entitled to Medical and Wage Benefits
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 the same medical treatment and wage disability benefits as anyone else injured on the job.
This is true whether your old injury was fully healed or not, and so 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 Ignores Doctor’s Orders
A mechanic working for a car dealership is injured when a portable hydraulic lift loses power and drops a car on him, severely breaking his leg. He files a workers’ compensation claim and receives full medical and lost wage benefits.
He’s released for work, but 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 leg to fracture.
The mechanic files a new 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.
Common Pre-Existing Conditions Arising with Work Injuries
Pre-existing injuries can include a herniated disc, 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 workers’ comp claim because of a pre-existing medical condition.
Many times, an injured worker simply gives up on the claim; however, insurance companies cannot legally deny an on-the-job injury claim based solely on a pre-existing condition.
Old injures can be anything from an old workers’ comp injury to a car accident or sports injury from years ago.
If you’ve previously been awarded workers’ compensation benefits for an injury and are now suffering an aggravation or worsening of the original injury, you may not be eligible to file a new workers’ comp claim, but you may be able to re-open your prior case.
Re-opening a prior workers’ compensation claim can be difficult. You’ll need an experienced personal injury attorney for the best chance of success.
Arthritis is a potentially disabling condition that affects more than 54 million people in the United States. But it’s not a condition limited to the elderly.
Two-thirds of American adults with arthritis are working age. That’s up to 36 million workers with just one kind of pre-existing condition.
Degenerative Disk Disease
Degenerative disk disease isn’t a true disease, it’s normal wear and tear to the cushioning disks in your spine. As we age, those disks can break down. If worn-out disks start hurting, it’s called degenerative disk disease.
You may not know you’ve got degenerative disk disease until you get hurt on the job and have X-Rays or a CT scan.
Nearly every working adult, especially older workers, will show up with some level of disk degeneration on scans, making it a pretty handy excuse for workers’ comp insurance companies to deny these claims.
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 worker’s back would not be hurting him or restricting his activities. 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 for paying the cost of any repairs it might need. While human beings aren’t cars, the “as is” principle is similar.
Don’t rely on the worker’s comp insurer to interpret the labor and compensation laws in your state. You have too much at stake and nothing to lose from a free consultation with a workers’ compensation lawyer about your work injury case.
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