To offer a different perspective on the subject of pre-existing conditions, we turned to our Legal Analyst with the firm, Vanessa Washington. Vanessa has extensive experience in the insurance industry with a focus on workers’ compensation. Vanessa’s primary role with Meuser, Yackley & Rowland, P.A. is to support the attorneys by analyzing the value of each case, providing case law research, and facilitating negotiations.
I worked as a Claims Adjuster for more than 13 years. Along the way I learned of a common, sometimes unspoken, theory amongst injured workers – a theory with little merit. Injured workers seem to be under the impression that a pre-existing injury or condition excludes them from being eligible for workers’ compensation benefits. This idea creates an uncomfortable space for injured workers resulting in late reporting or even non-reporting of work injuries. In some circumstances an injured worker may feel compelled to “bend the truth” when discussing the relevant facts of their case with the insurer, their claims adjuster and even their employer. What if I told you the misinformation you provide to the claim adjuster may jeopardize or at minimum delay your entitlement to benefits you would otherwise be entitled to receive? What if I told you a pre-existing condition doesn’t necessarily exclude you from being eligible for workers’ compensation benefits? There are no provisions in the work comp act that allow the adjuster or insurer to deny your claim on the sole basis of pre-existing condition. In actuality, the insurer should be working to identify their window of responsibility as it relates to your current complaints.
Failing to make your claim adjuster aware of a similar complaint can result in a denial of your benefits under mistake of fact. If the initial determination to accept liability was based on misinformation provided by you or a medical provider you are seeing, the insurer will likely deny your claim. In cases where the claim is accepted and the adjuster later becomes aware of the misinformation, the denial could potentially be retroactive to the first day you received benefits.
An insurer or claims adjuster will always need to complete a thorough review, or investigation, of your reported injury. This is the point when the adjuster should become aware of any past complaints of a similar nature. Through a review of medical records, the insurer must determine if the work injury or work activities aggravated a pre-existing condition, accelerated the symptoms of your pre-existing condition or substantially contributed to your current complaints. If one or all of these apply, your claim would likely be compensable and should be paid accordingly.
Following their review, the insurer will likely require additional information to assist them in identifying their duration of responsibility as it relates to your reported work injury. Is your work injury a permanent aggravation of the pre-existing condition or is your injury a temporary aggravation of the pre-existing condition? This identification process is typically completed through a review of your prior medical history followed by an independent medical evaluation (IME). In instances where the injury is deemed to be a permanent aggravation or acceleration, that duration of the insurer’s responsibility is indefinite.
Though there are no guarantees your workers’ compensation claim will be immediately accepted – honesty is the best policy. The insurer is more than likely responsible for something. Failing to provide information that could change the handling of your workers’ compensation claim will not provide you additional benefits. It’s best to provide the adjuster with the information they need to make an informed decision. If ultimately that decision is not in your favor, reach out to one of our qualified attorneys for a free, confidential consultation.