How Chronic Conditions Can Affect Your Workers’ Compensation Claim

One of the many benefits of the workers’ compensation program is that it is a no-fault insurance system. That means that you don’t need to prove that your employer caused the conditions that contributed to the injury accident. You can also file a claim if the accident was partially or entirely your fault.

Although the reasons for the accident won’t be a factor, your medical history will come into play. Just as you’ll need to submit all the records pertaining to your injury treatment, you also have to provide your medical history.

That’s when an insurer will discover your chronic condition and it could lead to a denial. This is how that could play out:

Applying the “Aggravation Rule”

Suppose your pre-existing chronic condition is degenerative disc disease. If you engage in heavy lifting on your job that exacerbates that condition, your employer is responsible for the costs of that aggravation. It might mean a partial or permanent disability that will affect your ability to work.

Apportionment Issues

That same issue with a bad back could be categorized as an apportionment issue.

That’s when an insurer will assert that your current symptoms are part of the natural progression of your condition. As a result, they could attempt to reduce your benefits payout.

Slower Recovery Times

Conditions like diabetes, obesity, or hypertension can complicate the recovery process.

That can increase the time that you’re out of work. An insurer can use that against you as another possible reason for reducing your benefits.  Even though the workers’ compensation program is designed to help injured workers, it’s still an insurance system that requires going through a claims and approval process.

In other words, receiving a workers’ compensation settlement is not automatic.

Medical Evidence Needed to Prove Your Claim

When you are injured on the job, you’ll need to file an incident report. That will lock in the time, place, and details of the accident. After that, you’ll seek medical attention, where even more reports will be generated. In order to prevail in your claim, you’ll need the following types of key medical evidence:

• Initial Medical Reports: These will be the first records created after your injury. They can include your emergency room charts, urgent care reports, or your first doctor’s visit report. They will establish your immediate symptoms and reinforce the timeline of the incident.
• Diagnostic Test Results: These will be the most objective evidence of the injury, such as X-rays, MRIs, CT scans, and nerve conduction studies.
• Physician and Specialist Notes: Once you’ve been diagnosed, you’ll be presented with detailed treatment plans. Along with your progress reports and evaluations from orthopedic surgeons, neurologists, or other specialists, your treatment plans will be part of your comprehensive medical evidence file.
• Causation Statement: You will need a written statement from your authorized treating physician explicitly confirming that your injury or occupational disease is directly related to your work duties.
• Work Restrictions & Capacity: This report documents what tasks you can or cannot perform.  That can include Functional Capacity Evaluations (FCEs) or Work Hardening reports.
• Prescription & Therapy Logs: You will also need to provide records detailing the medications you are taking, as well as any prescribed physical or occupational therapy sessions.

It might seem overwhelming at first, but there should be no problem collecting these reports along the way of your injury recovery.

Steps to Take If Your Claim Is Denied for Pre-existing Issues

It will be extremely frustrating to receive a denial letter from your workers’ compensation insurance carrier. Thankfully, that doesn’t have to be the end of your claims process.

These are the steps to take if your claim is denied:

Step 1: Review the Denial Letter

You need to carefully read the insurance company’s official notice. It will cite exactly why they believe the issue is pre-existing rather than work-related. That will be the basis for how you should proceed.

Step 2: Consult a Workers’ Comp Attorney

You will undoubtedly have many questions about your claim and protections. An attorney who specializes in workers’ compensation law will be in the best position to answer those questions and discuss your appeal options.

They’ll help you file your case, ensure you meet strict filing deadlines, and become your advocate during complex negotiations.

Step 3: Gather Comprehensive Medical Evidence

With the support of your attorney, you’ll gather all your updated medical records that will demonstrate any chronic condition you had before the job and the exact date your symptoms worsened.

Step 4: Request a Second Medical Opinion

As part of your company’s workers’ compensation program, you might have gotten a diagnosis and treatment from the insurance company’s doctor. Depending on your state’s laws, your attorney may request an Independent Medical Examination (IME) or a Qualified Medical Evaluator (QME). That can help fortify your claim.

Step 5: File a Formal Appeal

Once you have all your supportive evidence and necessary paperwork, you can file a formal appeal to your state’s Workers’ Compensation Board or equivalent state commission.

This preserves your right to have a judge evaluate the facts. Your attorney will be able to represent you at the appeal hearing.

Dealing with any kind of workplace injury is hard enough. When that matter is compounded by chronic conditions, you need to do all you can to protect yourself and the validity of your claim.

At Work Injury Advisor, we have many supportive resources to help you understand the workers’ compensation claim process.

You owe it to yourself to become fully informed.