Is A Pre-Existing Condition In Play?

When the Affordable Care Act became the law of the land, the term “pre-existing condition” was often used.


For the workers compensation industry, that same term is not all that uncommon. In fact, it can be used quite often. Take the following scenario:


Following a work-related incident, a good employer makes sure that his or her injured employee is seen by medical professionals; often more than a single type; and often over an extended period of time.


Since it is not uncommon for individuals to hold off going to the doctor for symptoms they are experiencing, there are times a condition is initially diagnosed after one is injured on the job.



More Than Meets the Eye


For example, an MRI after a head injury could in fact diagnose a tumor – clearly the tumor is not a result of the work accident and, therefore, not tied to the obligation of your workers comp program.


When a company’s medical advisor goes over the file and speaks to the employee’s treating specialist, the two doctors can talk over the medical issues peer-to-peer. The result is very credible evidence the injury is or is not tied to what has happened in the workplace.


Use the following tips in your email communication:


  • Make sure you include a claim number and all relevant addresses and contact information on the letter.
  • Explain the company’s medical advisor has gone over the employee’s medical records.
  • Explain the accident along with the recently diagnosed condition.
  • Demonstrate how physicians came to the conclusion that one is not the result of the other.
  • Make the adjustor aware of these physicians’ findings and that they will arrive soon.
  • Explain you will make contact with the adjustor once they have time to go over the notes to be sure you have proper evidence to turn down the claim.


One of the leading causes of litigation is the denial of a claim.  Anytime a claim is going to be denied, communication with the injured worker is critical for the individual to understand the reasons and documentation behind the denial.




Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, and founder of COMPClub an interactive training program teaching workers’ comp cost containment best practices.  Through this platform he is in the trenches on a monthly basis with risk managers, brokers, consultants, attorney’s, and adjusters teaching timeless workers’ comp cost containment strategies, as well as working with members to develop new tactics and systems to address the issues facing organizations today. This unique position allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact:

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