How Do Pre-existing Conditions Affect New Workplace Injury Claims?
Insurance is all about “peace of mind.” With the right policy, you know that if you’re hurt in an accident or sustain property damage, your insurance will cover your financial losses to help make you whole again.
Nowhere is that more important than with a workplace injury that is covered by your employer’s workers’ compensation insurance.
Workers’ compensation is a no-fault insurance program that covers medical expenses and a portion of lost wages if you’re out of work because of the injury. Although businesses must carry workers’ compensation insurance, there is no guarantee your injury claim will be approved. One reason might be the insurance company’s claim that you had a pre-existing condition.
Having a pre-existing medical condition does not automatically disqualify you from receiving workers’ compensation benefits after a new workplace injury. You might still qualify for medical treatment, wage replacement, and other benefits when a job-related accident aggravates or worsens an existing condition.
However, proving a connection between the workplace incident and current medical problems can complicate these claims. That is why you may need an experienced workers’ compensation attorney to help you through the claims process.
Defining Pre-existing Conditions in Workers’ Compensation
There have probably been many days when you’ve gone to work when you weren’t feeling 100%. Maybe you used up your sick days or thought you could power through. Other times, a pre-existing condition doesn’t prevent you from working. It is just present, and you manage it.
Common examples of a pre-existing condition that you can potentially work with include:
- Chronic back pain
- Prior spinal injuries
- Arthritis
- Degenerative joint disease
- Previous fractures
- Prior surgeries
- Respiratory conditions such as asthma
- Heart disease
- Other long-term illnesses
If you know about a pre-existing condition, you need to be upfront about it. The insurance carrier will review your medical history and will most likely uncover the condition.
If you tried to conceal that, it would work against you.
How Aggravation and Exacerbation Affect Your Claim
When you’ve been injured on the job with a pre-existing condition, you need to establish if that condition was aggravated or exacerbated. Although they sound similar, the difference between the two can directly affect the outcome of your claim.
Here’s how it breaks down:
Aggravation in Workers’ Compensation
An injury that aggravates a pre-existing condition alters the underlying physical structure or pathology. For instance, it could turn a minor degenerative disc disease into a new herniation. When this happens, the law treats it as a new work injury. That can qualify you for long-term medical care, surgery, lost wages, and permanent impairment benefits.
Exacerbation in Workers’ Compensation
An exacerbation of a pre-existing condition is considered a temporary flare-up. This causes a spike in pain or discomfort without changing your long-term medical baseline. It might lead to a brief recovery window with rest or minimal care prescribed by your doctor. Insurers generally cover only the immediate, short-term treatment and temporary lost wages until symptoms fade. Once you return to your pre-incident state, ongoing or natural disease progression is not covered as a new work injury.
For example, if you have arthritis in your hand, you might do a task that worsens it to the point that you can’t work for a week. After that, you return to work, but the arthritis is still there and will progress.
How Workers’ Compensation Insurers Decide
When presented with a claim that involves a pre-existing condition, a workers’ compensation carrier will conduct a thorough investigation to determine the extent of the injury.
First, they rely on medical evaluations from doctors who use Qualified Medical Examinations (QMEs) or Agreed Medical Examinations (AMEs) to determine what portion of your disability is work-related versus natural aging.
If an aggravation occurred, insurers often reduce permanent disability payouts based on the percentage caused by your prior condition. If you fail to tell your doctor about prior injuries to the same body part, it can lead to claim denials. It might also trigger a fraud investigation.
The Role of Medical Evidence and Expert Testimony
To prevail in a workers’ compensation claim, you need compelling medical evidence and possibly expert testimony. Your evidence needs to establish causation, which is proof that the injury or illness arose out of and in the course of your employment rather than a pre-existing condition or outside activity. This can be accomplished with the following types of supportive documentation:
- Physician notes
- Emergency room records
- Diagnostic imaging like X-rays and MRIs
- Surgical reports
- Functional capacity evaluations
You can also call on medical or vocational experts to provide testimony about complex medical test results or permanent impairment. Insurers often use their company-chosen or independent medical exams (IMEs) to minimize payouts or deny claims. The testimony from your medical experts can counter those assertions.
Vocational analysts can also support your claim by assessing any potential lost earning capacity.
It is understandable if gathering this evidence seems overwhelming. Fortunately, many skilled attorneys understand the applicable workers’ compensation laws and how a pre-existing condition can affect your claim.
Instead of falling down an online search rabbit hole, you’re better served reaching out to an attorney you can find through Work Injury Advisor. You don’t want to wait to get your questions answered and your claim filed.