Pre-Existing Conditions and Workers' Compensation Benefits Under the Law
The workers’ compensation system is designed to provide benefits for workers who suffer an injury in the course and scope of their occupation. Even jobs that are considered less physical than others can cause employees to experience debilitating injuries, like carpal tunnel syndrome and back injuries. Many workers, however, already have pre-existing conditions at the time they suffer a work-related injury. Although this is not a complete bar to receiving workers’ compensation benefits, it can make the process of determining the amount of benefits the worker should receive more complex.
Every state is required to maintain a workers’ compensation system, but the rules and regulations imposed can vary between jurisdictions. After an injured worker files a workers’ compensation claim, a medical provider will typically examine the employee to determine the nature and extent of the injuries. Virtually every state uses classifications to determine the type of benefits that an employee should receive. These classifications consider whether the injury is total, partial, temporary, or permanent. A permanent and total injury is the most severe type of injury that a worker can experience on the job. This typically means that the worker can no longer engage in any meaningful and gainful employment and will rely on workers’ compensation benefits for the remainder of his or her life. A temporary and total disability occurs when an injured worker will eventually heal but cannot work during until then.
You may be eligible to receive workers’ compensation if, while doing your job, a pre-existing condition is aggravated.
Naturally, a pre-existing condition makes it more difficult to determine whether the work-related injury is the cause of the employees’ symptoms that prohibit him or her from working, or whether those symptoms arise from the pre-existing injury. This is even more difficult when the pre-existing condition and the work-related injury are similar or affect the same body part. For example, if you have a history of arthritis in your right knee and you suffer an injury to your right knee at work, determining the amount of benefits to which you are entitled becomes more complicated. The reason that the symptoms of the pre-existing injury and work-related injury must be allocated is that most states only hold an employer responsible for the aggravation of your existing injury.
Additionally, if your pre-existing injury is associated with a prior workers’ compensation claim, you may still receive benefits, but your award will be reduced to account for the existing physical injury. If the second injury results in a permanent disability, your benefits will be offset to account for any permanent disability benefits that you received as a result of the original workers’ compensation injury.
In many instances, a workers’ compensation insurance company will deny the payment of benefits to an employee who has sustained a work-related injury that aggravates a pre-existing condition. Insurance companies cannot deny a claim solely on this basis, and negotiations are typically required between the insurance company and the injured worker’s attorney to reach a workers’ compensation settlement agreement. The insurance company is still required to pay the injured employee’s benefits, which compensate the employee for medical expenses, treatment, and future medical care. During a dispute regarding the nature and extent of an injury, the insurance company can request a Qualified Medical Examination or Agreed Medical Examination. During these proceedings, a neutral third-party medical provider examines the worker to determine the nature and extent of the injury, and the extent to which the worker’s symptoms are associated with the pre-existing injury.
The rules regarding work-related injuries that aggravate pre-existing conditions vary between states. Although many states allow employees to recover benefits for the aggravation of a pre-existing injury, some states deny benefits where the pre-existing condition was incurred as the result of a non-work-related injury.
Is It Truly Pre-Existing?
A new injury to a previously injured body part is a new injury, rather than a pre-existing injury. Thus, the recovery limitations placed on pre-existing injuries will not apply.