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How preexisting conditions can impact a workers’ comp claim

On Behalf of | Jun 8, 2024 | Workers' Compensation

A preexisting condition is any health problem that existed before a workplace injury. Common examples include back problems, arthritis and old injuries.

When a new injury occurs at work, employers and insurance companies closely examine the worker’s medical history to determine if the current injury relates to the preexisting condition.

Benefits eligibility

Preexisting conditions can impact workers’ compensation eligibility. If the preexisting condition is the primary cause of the injury, claim denial may occur. For instance, if a worker with a history of back issues files a claim for a back injury, the insurance company might argue that the injury resulted from the existing back problems not a workplace injury.

Compensation amount

In 2020 and 2021, the average cost of workers’ compensation for workplace accidents was $41,757. However, preexisting conditions can impact workers’ compensation payouts. The insurance company might only cover the portion of the injury that is directly related to the workplace incident. Through this apportionment process, insurance companies divide the compensation based on the extent to which the work incident and the preexisting condition contributed to the injury.

Additional scrutiny and investigation

Insurance companies may require detailed medical records and independent medical examinations to assess the extent of the injury and the role of the preexisting condition. This can prolong the process and sometimes lead to disputes over the claim’s validity.

Be honest

Employees need to report all injuries and preexisting conditions honestly. Failing to disclose a preexisting condition can result in the denial of the claim or charges of fraud. Accurate reporting ensures that the medical professionals and the insurance company can make a fair assessment.

Preexisting conditions can complicate workers’ comp claims. Employees need to understand these impacts to manage their claims effectively and ensure they receive the benefits they deserve.