How To Appeal a Denial Based on Pre-Existing Conditions

After a serious work injury, your employer may deny your claim and blame your injuries on a prior condition. While pre-existing conditions complicate your workers’ comp claim, you can still get benefits. Work injuries that aggravate pre-existing conditions qualify for workers’ comp benefits.

Workers’ compensation laws differ in every state. If the insurance company denies your claim based on a pre-existing condition, talk to a workers’ comp lawyer. Contact a local workers’ compensation attorney to appeal your workplace injury.

Workers’ Comp Coverage for Pre-Existing Conditions

Workers’ compensation insurance gives injured workers benefits after a work-related injury. Benefits include wage loss income and medical treatment for the injury. Workers’ compensation benefits help injured employees until they can return to work.

Qualifying injuries include any traumatic injury, illness, or disease caused by employment. Injuries also include aggravation of a pre-existing condition. If you have a pre-existing medical condition and your job is worsening the symptoms, workers’ comp should cover the claim.

For example, a nurse has a prior back injury from a car accident. While lifting a patient, the nurse suffered a herniated disc, causing severe pain and limited mobility. This workplace accident should qualify as a workers’ comp new injury since it aggravated an existing injury.

Understanding Pre-Existing Conditions

Many workers have pre-existing conditions that never affect their work performance. Common examples of pre-existing conditions include:

• Arthritis
• Back injury
• Carpal tunnel syndrome
• COPD
• Depression
• Herniated discs
• Knee injury
• Neck injury
• Post-traumatic stress disorder

For example, an old sports injury could cause knee pain. A prior slip-and-fall can cause back pain. After recovery, you continue doing your job. However, a new workplace accident can cause more injuries and worsen your conditions. These are the result of a work-related accident.

Unfortunately, many insurance companies will try to deny coverage for pre-existing injuries. The insurance carrier can save money if they think they can disclaim your benefits. They won’t have to pay your medical bills or disability benefits. If the insurance company finds out about a pre-existing injury exacerbated by the accident, you can expect a claim denial.

After the insurance company denies your workers’ compensation claim, it’s up to you to pursue your case. The dispute process depends on your state law. You can request a hearing, reconsideration, or arbitration with your workers’ compensation board. After the final decision by your state commission, you can file an appeal with the state court.

In a dispute, the insurance company has to show that your pre-existing condition is responsible for injury or disability. If the condition you had before the accident is the primary cause of your injury, the accident may not qualify as a new injury. You can defend your case by showing how the aggravation caused your disability.

Gathering Evidence To Support Your Appeal

During the claim disputes, you can present evidence to support your workers’ compensation case. Evidence can include medical records, testimony, and expert testimony to support your claim. You can include worker testimony from people who witnessed the accident. You can also get expert reports to show how the workplace accident made your condition worse.

Insurance Company Challenges to Workers’ Comp Claims

The insurance company can also present evidence to deny your workers’ comp benefits. Most states let insurance companies request an independent medical examination (IME). An IME claims to be independent. However, the insurance company generally pays the medical examiner.

Disputed claims often involve different medical experts disagreeing on the cause and extent of the injuries. It’s up to the workers’ compensation board or administrative law judge to decide.

Working With Medical Professionals and Occupational Experts

You will work closely with medical professionals and occupational experts during the appeal. Your treating physician will continue to provide medical treatment for your work injury to help you recover. However, you may also have evaluations by other doctors to diagnose your injuries.

Occupational experts can assess your condition to see how your symptoms and injuries affect your work options. These experts can write up expert reports and give their expert testimony in court hearings.

Legal Advice for Your Workers’ Compensation Appeal

Going through the workers’ comp appeals process is frustrating. After suffering a work injury, your employer denies your injuries. Then, while you suffer pain and disability, your employer claims it’s all caused by prior health conditions. You have to deal with the appeals while you suffer pain and try to recover. A workers’ comp attorney can help you through the claims process.

An experienced lawyer can explain your options and represent you in workers’ comp hearings. They can negotiate with the insurance company for a settlement to cover your injuries. Most workers’ comp lawyers will offer a free case evaluation. Reach out to a workers’ compensation lawyer for help through the appeals process.