Will Workers’ Compensation Cover Pre-Existing Conditions? – by John Connell, Of Counsel – Burg Simpson Eldredge Hersh & Jardine
If you have been injured on the job or in the line of duty, you can file a workers’ compensation claim to receive benefits to cover your medical bills and lost wages. But what happens if an injury or repetitive activity in the workplace aggravates a preexisting condition? It is possible that workers’ compensation insurance will cover work-related injuries that worsen pre-existing conditions, but filing this kind of claim can be more complicated than filing a claim for a new injury.
Seeking New Treatment for a Pre-Existing Condition
Although many insurance companies, employers, and health care providers appointed by the employer’s insurance company will attempt to deny coverage for pre-existing conditions, a claim that a work injury has aggravated a pre-existing condition can be compensable under certain circumstances.
There are two primary factors that are going to go into determining if a pre-existing condition is covered by Colorado workers’ compensation. The first thing the insurance carrier is going to look at is whether you have been treating, or complaining of, pain or loss of mobility in the affected area in the last few years prior to the date of your injury. They will ask for a medical release for at least the last 5 years and the names of all facilities or doctors that have treated you for any condition. They will obtain these records and look at whether there is ANY complaint of pain or problems with this body part, even those that are minor. The more time that has passed since your last injury or treatment for that body part the better in this situation.
The second thing that they will do if it is an age-related condition like arthritis or degeneration is to have a physician that they choose (and who make a lot of money doing reviews like this) review your records and given an opinion on whether it is a natural progression of the age-related condition or if there was a change in your medical treatment for the pre-existing condition following your work-related injury. For example:
- A new need to seek treatment for a pre-existing condition. (i.e. you were not seeking medical care for your pre-existing condition, but following the work-related injury you are now seeking to obtain medical care for your pre-existing condition.)
- An increased need to seek treatment for a pre-existing condition (i.e. Physical therapy for your shoulder had been providing relief for your pre-existing condition, but following the work-related injury you will now require shoulder replacement surgery.)
- An accelerated need for treatment of your pre-existing condition (i.e. Your physician indicated that you will need shoulder replacement surgery in 5 years, but following the job-related injury, the doctors are now recommending that you schedule the surgery immediately.
These reviews frequently deny that the condition is work related so if this occurs you will need to see an attorney to pursue the claim through the Administrative courts. This doctors opinion supports the insurance companies denial and often can be overcome at a hearing. The attorney can review the records and make recommendations on how to proceed, and whether an opinion of a doctor that is chosen by the attorney is needed.
Document Your Injury and Your Treatment
The best way to ensure that your employer’ workers’ comp insurance carrier covers the workplace injury that aggravated your pre-existing condition is to be as prepared as possible. Report your workplace injury immediately following the incident and make sure that you keep detailed notes regarding the circumstances that led to your injury and your subsequent medical examinations and treatments. You will be asked when you get to the doctor’s office if you have any prior injuries to this area and it is good to be upfront and honest about them because those records will come out, and a failure to mention it initially will cause you to look less credible.
Make sure that when you see the company authorized physician that you indicate how this injury has made the condition much worse, especially if you have not had any treatment or limitation in your activity in the year or two prior. If you had an acute injury (I fell or lifted something, twisted and had immediate pain to the area) then make sure that they know that prior to this you had no pain or problems doing what you wanted to do. If you had restrictions or limitations say how you were able to do what you had to do within those prior to the time of the incident.
If it is an occupational disease claim (no specific injury, just a worsening of pain or limitation over time) it is a much harder claim. Talk to the attorney before you talk to the company about it if possible. If you have seen the company doctor or already reported the injury you will likely need a physician’s testimony to explain how work has accelerated the underlying condition, and can almost be assured that they will deny the claim.
Consulting with a Workers’ Comp Lawyer at Burg Simpson
Even if your employer and the insurance company state that your pre-existing condition is not covered under Workers’ Compensation, you should still schedule a free consultation with an experienced Workers’ Comp attorney who can evaluate your claim and evaluate the evidence in your case. it is important to know that f you do choose to represent yourself at a hearing, you will be held to the same standard as an attorney practicing workers’ compensation law, and will be expected to have knowledge of the law and rules of workers’ compensation in the State of Colorado. Burg Simpson has been working on these types of complex cases for more than 40 years and we are familiar with the ins and outs of Colorado’s complicated workers’ compensation law.
Call Burg Simpson Today
If you have been injured on-the-job or in-the-line-of duty, let the professional workers’ compensation lawyers at Burg Simpson help you:
- Receive fair compensation for your injuries
- Have access to quality medical care
- Understand your legal rights within Colorado Workers’ Compensation laws
- Obtain reimbursement for the legitimate expenses you have incurred during your injury
- Apply for additional Social Security benefits
- Explore third-party personal injury lawsuits
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