Does Workers’ Compensation Cover Pre-Existing Conditions?
Coverage for workers’ compensation claims can be confusing, especially if you have a chronic condition or developed a health condition due to repetitive motion injuries. Some people may not seek the treatment or claim benefits they’re eligible for because they think the answer to “Does workers’ compensation cover pre-existing conditions?” is no.
That may not be the case, though — some situations in which pre-existing conditions and workers’ compensation coverage overlap. A skilled personal injury attorney, like those at Wenzel Fenton Cabassa, P.A., can help you learn what benefits you’re eligible for and appeal a benefits denial.
What Is a Pre-Existing Condition?
Workers’ compensation covers chronic illnesses or health conditions developed while on the job (like repetitive motion injuries, back strains, or respiratory conditions caused by toxic exposure).
Pre-existing conditions such as a bad back or asthma may have existed before the individual started working at the company but were exacerbated due to the working conditions or their job duties. These employees may legally be eligible for medical treatment under their employer’s workers’ compensation pre-existing conditions policy.
Regarding pre-existing conditions, workers’ compensation will cover treatment in some cases when the individual did not know they had the medical condition or were asymptomatic when they were employed at the company.
For example, suppose someone worked in construction around insulation containing asbestos and later developed mesothelioma from toxic asbestos exposure. In that case, that individual could make a valid case for why they should receive workers’ compensation benefits — they were injured on the job because their job duties caused them to be exposed to known carcinogens.
A pre-existing condition in the context of workers’ compensation benefits is considered a health condition that an individual had before starting their workers’ compensation claim.
Because the person had an injury or chronic illness before they filed a claim for workers’ compensation benefits, it can be tricky for the insurance company to determine whether the problem was caused or aggravated by the person’s job duties or whether the condition did not worsen during the employee’s tenure with the company.
When someone is asymptomatic for months or even years after exposure to toxic substances, or there aren’t immediate symptoms of a severe repetitive motion injury or strain, it is difficult for doctors to pinpoint the root cause when serious symptoms do present.
Some health conditions may have an easily attributed cause, like asbestos-related mesothelioma, while others, like a slipped disc in the back or carpal tunnel syndrome, may have many possible initial causes.
Pre-Existing Conditions and Workers’ Compensation
In some cases, an employee may be covered by workers’ compensation, and their pre-existing conditions can be treated under that coverage. Workers’ compensation insurance aims to provide quality medical care for employees injured on the job and financial support for the employee as they recover from their workplace injuries.
In other situations, the employee’s pre-existing condition may be treated during medical care after a workplace accident.
For example, if you have carpal tunnel syndrome and slip and fall at work, breaking your wrist, then surgery to treat the broken wrist may also cure the carpal tunnel syndrome. Or if you have a bad back and hurt yourself lifting something while working, you can still claim workers’ compensation for the back injury.
If you have a pre-existing injury, workers’ compensation claims must be noted; employers usually require their insurance company to disclose this. That’s because, under Florida law, you must prove that your workplace injury was a Major Contributing Cause (MCC) of your current condition.
Here are some key points about the MCC principles in Florida:
- You must prove that the work-related condition is more than 50% of the cause for your current condition
- Insurance carriers often use MCC as a basis for a claim denial
- If your workplace injury worsens an old injury, you cannot file a claim for additional pain
- Your attorney must prove MCC with medical evidence and objective findings
If you previously filed a workers’ compensation claim for a work-related injury and this injury contributed to your current condition, then you may have an easier time proving MCC in your current case.
Determining Coverage for Pre-Existing Conditions
In which situations does workers’ compensation cover pre-existing conditions? It depends on the specifics. Insurance companies determine coverage for pre-existing injury and workers’ compensation based on the nature of the workplace injury and the severity and nature of the pre-existing condition.
Good medical documentation will improve your chances of having the insurance company consider your claim to be valid.
As soon as your health condition worsens because of your job duties each day, alert your supervisor and start the workers’ compensation claims process. Your employer will create an incident report including the nature of your injury or illness and a description of your job duties.
Next, see the doctor indicated by your employer. Workers’ compensation coverage may not extend to your own doctor; employers must select a doctor or medical center for their workers’ compensation policy. The doctor you see will be referred to as your treating physician in your workers’ compensation paperwork.
To retain coverage for your illness or injury, you must follow all directives of the treating physician, from wearing a sling or support device to performing light duty at work or taking certain rest periods to heal.
Keep any documentation related to the injury or exacerbated existing condition, including:
- Copy of the incident report or workers’ compensation filing from your employer
- Diagnosis from the treating physician
- Recommendations for healing and recovery for the treating physician
- A daily log of your condition, including pain levels and their effect on your life
- Documentation of any second medical opinion you seek
- Bills and statements from treatment
- Accounting of lost wages because the injury prohibited you from working
The paperwork is part of the evidence that your personal injury lawyer may need to build a case for damages if your workers’ compensation claim is denied.
The Importance of Medical Documentation
Medical documentation is critical in answering the question, “Does workers’ compensation cover pre-existing injuries?” However, you may need more than just the documentation of your injury and diagnosis from the workers’ compensation treating physician. Your employer’s workers’ compensation insurance carrier may ask for documentation that you were diagnosed with a pre-existing condition.
Your treating physician may refer you to a specialist for a back injury or a surgeon to correct carpal tunnel. Save all documentation related to that, and ask for the referral in writing. As you heal, ask for updates on your prognosis in writing to add to your records.
Workers’ compensation coverage generally ends when the recipient reaches Maximum Medical Improvement (MMI) as determined by the treating physician.
When you have reached this point, collect the written confirmation of your treating physician that either you are fully recovered from the workplace injury or you cannot reasonably expect further recovery or improvement of your medical condition.
Your medical records serve as evidence to your employer’s insurance company that your on-the-job injury did contribute to the worsening of a pre-existing condition. If you file a lawsuit, these records will be a critical part of your personal injury attorney’s arguments in your favor.
Without medical documentation that states how the injury occurred and that it occurred in the general course of work as you were doing your assigned duties (i.e., your injury wasn’t the result of you being reckless or negligent at work), a workers’ compensation insurance company is unlikely to approve your claim.
Impact of Pre-Existing Conditions on Workers’ Compensation Benefits
The impact of your pre-existing condition on your workers’ compensation benefits and eligibility varies depending on your specific situation.
In some cases, your benefits may be reduced because your health or possibility of recovery is compromised due to the pre-existing condition. In other cases, though, there may be no impact on your benefits because of your pre-existing condition.
Several factors come into play when the insurance company is approving your benefits:
- Your medical history, including the pre-existing condition
- The type of illness, injury, or condition for which you’re seeking treatment
- Evidence to support your claim that you were hurt on the job
- Whether your pre-existing condition led to the workplace injury
These may not be the only factors an insurance company considers, but any of these may be a reason the insurance company gives for denying your claim.
You do have the right to appeal the insurance company’s decision about your coverage and benefits amount, but these appeals can be quite complex, from the initial filing paperwork to constructing a strong case for your benefits.
A skilled personal injury lawyer with experience in Florida workers’ compensation appeals can greatly help at this point. Your attorney files the claim, constructs your case, and argues on your behalf before the state appeals board.
How to File a Workers’ Compensation Claim for a Pre-Existing Condition
To determine whether workers’ compensation will cover your pre-existing condition, start by filing your initial workers’ compensation claim. Even if you are considering filing a workplace injury lawsuit for damages against your employer, you must start with the workers’ compensation claim.
You may need to provide information about your pre-existing condition, so before filing your claim, gather copies of medical records that detail the initial diagnosis and any pre-existing condition limitations.
To file a workers’ compensation claim in Florida for aggravation or worsening of a pre-existing condition, follow these steps:
- First, report the injury or illness to your employer and follow the procedures for a workers’ compensation claim
- Seek medical attention from the employer’s workers’ compensation doctor
- Gather your medical documentation and evidence using the list above
- Record any witness statements, like those of co-workers who were present when you got hurt
- Keep a log of any relevant information about your workplace injury, pre-existing condition, and current condition
Finally, retain services from a workplace injury lawyer familiar with litigating cases under MCC.
Your lawyer can help you gather the right information to build a strong case, file any paperwork on your behalf, and argue before the Florida Workers’ Compensation Appeals Board. You can learn about your legal rights and what to do (and not do) to ensure better approval of your claim.
The Role of a Lawyer in Workers’ Compensation and Pre-Existing Conditions
With a talented legal team of Florida personal injury lawyers working on your claim, you stand a better chance of having your claim or appeal approved for workers’ compensation benefits.
We offer that team. Wenzel Fenton Cabassa, P.A., focuses on helping peoplepursue workers’ compensation claims, from appeals to litigating a lawsuit in court. Contact us today for a consultation with an experienced workers’ compensation lawyer