Does Workers Comp Cover Aggravated Pre-Existing Conditions?

Aggravating a pre-existing injury or illness while on the job is among the trickiest areas of workers compensation law. In short, you will be in a battle from the get-go. An adverse condition suffered before your work-related mishap could seriously limit your workers comp benefits.

Consider the various maladies commonly endured by adults in the workforce: arthritis, back trouble, joint inflammation, knee and/or hip pain, heart disease, diabetes, asthma, even mental health concerns.

The list certainly doesn’t stop there. The point is, because your employer and its workers compensation insurer are duty-bound to cover the job-related worsening of your old injury, it’s in their interest to demonstrate the source of your impairment is the pre-existing condition, not the job-connected incident.

We’ll note this up front: For a successful outcome, you will most likely need help from a workers comp attorney.

Can You Get Workers Comp for Aggravating a Pre-Existing Condition?

Let’s get this on the record straightaway: Because workers compensation is a state-based system, it is impossible to say with confidence what happens in your specific state regarding job-related aggravations of pre-existing conditions.

Most states obligate employers to provide benefits to workers even under the pre-existing condition scenario. Most. Not all. And, from coast to coast, the devil is in the details.

Here’s the only thing absolutely safe to say about whether your condition, aggravated at work, qualifies for coverage, and the degree to which you can claim benefits: It depends.

“Pre-existing condition cases are fact specific,” says Michael Keough, who’s been practicing workers comp law in the Tampa Bay Area for 27 years. “The milder and [more] remote the pre-existing condition, the stronger the workers compensation case.

“Perhaps the claimant had a [traffic accident] 10 years ago, recovered in a few weeks, and returned to work. This scenario would likely result in a compensable claim.”

There’s wiggle room on all sides, so it’s essential to have expert professional help to pin the facts and circumstances. You are not automatically disqualified from workers compensation benefits just because you have a pre-existing condition. It does, however, make your claim more difficult to prove.

How Does Having a Pre-Existing Condition Affect Workers Comp Claims?

The effect of a pre-existing condition on your workers comp claim presents a kaleidoscope of possibilities. Is the pre-existing condition the result of another workplace injury? Or did you aggravate an old high school football mishap? You separated a shoulder in a fall while hanging Christmas lights. How much of that is responsible for your shoulder injury while doing heavy lifting at work? Is your carpel tunnel pain a result of workplace keyboard work, or is that just your tennis elbow acting up?

Plainly, a pre-existing condition complicates a medical professional’s ability to produce a precise diagnosis. Did the work-related injury create the symptoms that prevent the employee from working? Or is it the pre-existing condition?

It’s even more difficult when the pre-existing condition and the work-related injury are similar or affect the same body part. Suppose you injure your arthritic left knee at work. Where does the pre-existing condition end, and the injury kick in?

“[Claimants] have to be truthful,” Keough says. “When they go to the doctor, they should tell them about prior problems they have. Then they have the ability right then to put it in the context that they want to put it in.

“So, I can say, ‘Yeah, I had a problem 5-6 years ago, but that all resolved, I’ve been doing great since.’ … A  normal doctor would say he was doing fine, so the [work-related] accident is the major contributing cost.”

More problematic: Workers who have ongoing treatment, or who see a pain-management specialist regularly.

This is a crucial distinction: Most states hold employers responsible only for the aggravation portion of your injury. These often wind up being close questions, the answers to which could have a profound impact on your employer’s obligation to pay for medical treatment and/or lost wages.

Proving a Work-Related Injury with a Pre-Existing Condition

As noted above, this is exceptionally tricky, complicated territory, overflowing with nuance. When pre-existing conditions are in the mix, employers’ workers comp insurers have professionals who are experts at shifting blame away from the job-related injury.

The process begins, as all workplace injuries do, with an evaluation by a doctor — one, most likely, chosen by your employer. Such a physician will be well-versed in workers compensation rules, phrases, and terminology. (They also will know who pays their bills.)

Your post-consultation report will note whether your job-related injury worsened your pre-existing condition, and whether this aggravation is temporary or permanent.

It’s not unusual for an injured employee to disagree with the doctor’s diagnosis. In most states, workers comp allows claimants to seek a second opinion from a doctor of their choosing. But how do you choose?

Remember, the insurer has professionals committed to fulfilling the company’s business model: collecting premiums and limiting claims. You probably need experts on your team.

Experienced workers comp lawyers in your area know and work with nearby employee-friendly workers comp doctors. Once retained, a workers comp attorney will secure, and front the payment for an independent medical evaluation — the first step toward proving your case.

A reminder: Workers comp laws are state-specific. What is required and expected in Michigan may not be required or expected in the statutes in Pennsylvania or Montana. Many states allow benefits for aggravated pre-existing conditions, no matter how the condition came about; other states deny benefits if the condition resulted from a nonwork-related injury.

What about Injuries Associated with Prior Workers Comp Claims?

Sometimes, employees suffer reinjury in an area linked to a previous workers comp claim. Again, this, in all likelihood, will be a complex case. Maybe your claim for new benefits will be offset by your previous claim. Maybe not. Once again, the frustrating answer is: It depends.

Aggravating a Previous Work-Related Injury

Remember that lousy shoulder mentioned above? If you strained it at work, rather than while replicating Clark Grizzwald’s Christmas Vacation misadventures, mostly recovered from the original injury, then strained it again, your benefits might be reduced to balance the pre-existing condition.

If there’s a permanent disability diagnosed, that benefit will shrink if you received permanent disability payments for the original workers comp injury.

Wait. There’s more. Was the previous work-linked injury one from which you could expect to recover fully? Injure that body part again, which might qualify as an absolutely new event. Which brings us to …

New Work-Related Injury to the Same Body Part

Often, there is a subtle, but vital, distinction between the aggravation of an earlier work-related malady and a brand-new injury involving the same body parts.

Be honest, open, and above all, consistent with your doctor regarding your previous workplace injury. If you have medical records related to the old claim, provide a copy to your doctor. This will help determine if your injury is a continuation of the old one, or a new, but related, injury.

This is no small thing. If the new injury is diagnosed as an aggravation, you must complete the paperwork for a “worsening” appropriate claim. A new workers comp claim is required if the physician determines the injury is specific to the current incident.

Secondary Injuries

We are not yet out of the woods. Occasionally, secondary injuries — injuries that result from qualifying primary injuries – crop up. These, too, qualify for workers comp benefits … if they can be proved.

Claims for secondary injuries can be incredibly complex because they may arise days, months, even years after the original injury or treatment.

Often, the employer and insurer will attempt to deny workers comp coverage, arguing the secondary injury isn’t work-connected, or the claimant lacks proof the secondary injury is linked to the primary damage.

Types of secondary injuries include:

• Anxiety, depression, PTSD
• Arthritis
• Blood clots
• Complications from medical treatment, surgery, or therapy
• Infections
• Loss of sensation or range of motion, persistent tingling
• Prescription drug dependency or side effects

A successful workers comp claim for secondary injuries requires clear evidence that the primary injury (or illness) was the triggering factor.

“For example,” Keough says, “suppose a claimant injured his or her low back and had surgery and during recovery was prescribed a cane for balance and subsequently developed carpel tunnel syndrome.

“As long as the surgeon or another authorized doctor opined the carpel tunnel was a result of the cane and the cane was a result of the injury, the carpel tunnel would be compensable.”

Once the linkage is established, the secondary injury qualifies for workers comp benefits, including medical treatment, lost wages, and, potentially, some sort of settlement.

Again, this is challenging territory to navigate without experienced, expert help. Consulting a workers comp attorney will help you discover where you stand, whether your case is worth pursuing, and what to expect from the process.