In workers compensation claims, a pre-existing condition refers to a medical condition the employee had prior to the occurrence of the work comp injury. The pre-existing condition can be injury related, for example, a prior back injury, or the pre-existing condition can be non-work related, for example, degenerative disc disease.
The workers’ compensation laws of every state varies significantly in how each handles the aggravation of a pre-existing condition. The majority of states consider the aggravation of a pre-existing condition to be a part of the new work comp injury. Some states will accept the aggravation of a pre-existing condition that resulted from a prior injury but will not accept the aggravation of a pre-existing non-work related condition as a part of the work comp claim.
Aggravation of a pre-existing condition can be either a temporary condition or a permanent aggravation. It is important to the work comp adjuster to distinguish the difference, as the distinction can be critical to the outcome of the claim. The adjuster normally will allow for disability benefits for the period of time the employee is unable to work due to the aggravation of the pre-existing condition. The employee should not be compensated for the disability caused solely by the underlying condition.
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A typical pre-existing condition claim is the aggravation of the lower back. The employee reports s/he injured his/her back. The medical provider determines the employee has strained back muscles and has degenerative disc disease. The employee is taken off work while the back strain resolves. The employee continues to complain about the injury beyond the time it should take to heal. The medical provider realizing the muscle strain should be resolved returns the employee to work with a 20 pound lifting restriction. The lifting restriction is to protect the employee from aggravating his/her degenerative disc disease, not to protect the employee from straining the back muscles again. As the restrictions arise out of the employee’s pre-existing condition, they can be disputed.
However, the employee with the pre-existing condition is a greater risk for another injury. Requiring the employee to return to the same work as before without protecting the employee from his/her own pre-existing condition will often result in another aggravation of the pre-existing condition. Therefore, it is often better for the employer to honor the restrictions, even though the restrictions arise from the pre-existing condition, and not the work comp injury. If possible, you should consider re-assigning the employee to a different position where the potential for aggravation of the pre-existing condition is not as great.
Work comp claims involving the aggravation of a pre-existing condition need to be handled by experienced work comp adjusters who have in-depth knowledge of how these types of claims are handled within their state. The work comp adjuster should try some of these approaches to handling the claim involving the aggravation of the pre-existing condition:
- The adjuster and the employer should work together to arrange for a light duty return to work for the employee. Returning the employee to work on modified duty is always a good idea, but it becomes especially important in the claims involving the aggravation of a pre-existing condition. By returning the employee to light duty work, the employer reduces the likelihood of the medical provider placing the employee on permanent restrictions.
- The adjuster should investigate the claim thoroughly including interviewing the employee’s supervisor and coworkers to ascertain if the employee was having problems with the pre-existing condition prior the on the job injury. This is especially true with the un-witnessed “accident.” There may be information available to document that the work comp accident is not the cause of the employee’s medical problems but the pre-existing condition is the cause of the medical problems.
- The adjuster should not hesitate to question the medical provider about to the pre-existing condition. If the adjuster ask the medical provider “what caused the degenerative disc disease?” the medical provider can only indicate it is a condition of aging, and was not caused by the on the job injury.
- The work comp adjuster should reject work restrictions on the employee based upon the employee’s fear, or the medical provider’s fear, that a new injury could occur. The adjuster should work with the employer on arranging for a job revision that will reduce the employee’s chances of re-aggravation of the pre-existing condition.
- The adjuster should make sure the medical provider has a complete job description of the employee’s position. (It will be much more accurate than the job description most employees will provide to the physician). The job description should include the employee’s duties and the duration of each activity during a day. By providing the medical provider with this information, the physician can make a more accurate assessment of the employee’s abilities to return to his former job, which will limit the extent of the job restrictions placed on the employee and his pre-existing condition.
As an employer, you need to protect your company from higher than normal workers’ compensation cost brought on by the aggravation of pre-existing conditions. Pre-employment screening of job applicants is the most effective way of preventing work comp claims that arise out of the aggravation of a pre-existing condition. By not hiring people who will be more susceptible to injury, you can significantly reduce your exposure to injury claim involving the aggravation of a pre-existing condition.
However, employers must follow all EEOC/ADA guidelines to avoid discrimination charges.
The cost of background checks and physicals is minor compared to what a new employee with a pre-existing condition can do to your Experience Modification Factor.
As an employer you will never totally eliminate the injury claims involving the aggravation of a pre-existing condition. You can significantly reduce the number of injury claims involving pre-existing conditions by carefully screening the employees you do hire. Once the work comp claim occurs, you should work closely with your adjuster to minimize the impact of the pre-existing condition on the injury claim.
Author Rebecca Shafer, Consultant / President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact: RShafer@ReduceYourWorkersComp.com or 860-553-6604.
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers’ comp issues.
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