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How Do Pre-Existing Conditions Affect a Workers' Comp Claim?

If you have a pre-existing condition, you might be concerned about filing for a workers’ compensation claim – especially if the pre-existing condition is related to your claim. Some people might think it’s hopeless to file for workers’ compensation under these circumstances, but it’s not. While pre-existing conditions can make your claim more difficult to prove, they don’t automatically disqualify you from benefits.

What Is Considered a Pre-Existing Condition?

Pre-existing conditions are illnesses or injuries that precede a workplace accident injury. Pre-existing conditions can come from one’s childhood, a car accident, a bad fall, or even a previous workplace injury. The point is that they are medical conditions that existed to some extent before the workplace accident pertaining to the workers’ compensation claim.

Will a Pre-Existing Condition Cause a Denial of Workers’ Compensation Benefits?

Not always, but you can count on your employer’s insurance company to try to deny you benefits. If you want to pursue your workers’ compensation claim, you’ll have to release your relevant medical records to the insurance company. This is part of its investigation process, which is entirely devoted to looking for reasons to deny your claim or payout as little as possible.

If the insurance company discovers, for example, that you had a herniated disc from a car accident three years ago, it might argue that’s the real reason you’re suffering from back pain – not because you’re feeling the effects of a repetitive trauma injury from work. In a particularly egregious scenario, the insurance company might attempt to attribute an unrelated pre-existing condition to the impact of a workplace injury.

It would need a physician to make that determination of course, but that might not be such an obstacle when you’re required to go to the insurance company’s preferred doctor.

When a Workplace Injury Aggravates a Pre-Existing Condition

California workers’ compensation covers injuries related to pre-existing conditions provided that workplace accident created a “new” injury by aggravating an old one. This can occur, for example, when an employee with osteoporosis falls and breaks their arm at work. Even though having weak bones significantly contributed to the employee’s broken arm, the latter is a new injury that occurred because the accident aggravated a pre-existing condition.

Sometimes a work injury that aggravates a pre-existing condition will be covered to the maximum possible extent. In most cases, though, claims adjusters will look for a percentage to attribute to both the workplace accident and the pre-existing condition.

In our previous example, a physician might assign 40% of the responsibility for the employee’s broken arm to their osteoporosis and 60% to the fall. That means the employee may only receive 60% of what they could have otherwise gained in benefits.

What Happens If I’m Denied Workers’ Compensation Benefits?

If you are denied benefits, you can appeal the decision before your local Workers’ Compensation Appeals Board Judge. This will take place as a hearing, which is sort of like an informal trial. You’ll have a chance to argue why you believe the denial is inappropriate, and the insurance company will have an opportunity to defend its decision.

After considering both arguments, the judge will decide whether or not the insurance company must honor the claim and provide benefits. In a best-case scenario, you won’t reach this stage, and the insurance company will reverse its decision and try to settle before reaching the administrative court.

If your claim is denied, though, the first thing you need to do is contact a workers’ compensation attorney to help you appeal the insurance company’s decision. We at Smolich and Smolich are experienced advocates for people who have had to do this, and we’ve helped many achieve the results they needed to see a payout of workers’ compensation benefits.

If you’d like to learn more about what we can do for you, please contact us online or call (916) 571-0400 to schedule a consultation.