Sometimes a workplace accident aggravates a condition that already exists. In that case, the worker should receive workers’ compensation benefits for medical care required to treat the worsened pre-existing condition, as well as wage-replacement payments if the employee misses work.
A pre-existing or partly pre-existing injury should not be an excuse to withhold the benefits you deserve. Unfortunately, employers and workers’ comp insurance administrators often cite pre-existing injuries when they attempt to deny workers’ compensation claims. They argue that the worker’s current disability and need for medical care are due to the pre-existing injury, not a workplace accident, and are therefore not covered.
In such a case, the worker needs help from a physician who can distinguish the old injury from the new one and an attorney who will aggressively argue their case. Persuasive medical evidence will be needed to substantiate your claim.
In North Charleston, a workers’ compensation attorney at Joye Law Firm can help you obtain a second medical opinion and fight for the full benefits available under South Carolina law to injured employees. Contact us today!
What Is a Pre-Existing Condition?
A pre-existing condition is a medical impairment an individual had been diagnosed with or received treatment for before a new work-related accident. When rating the worker’s impairment upon maximum medical improvement (MMI) after the new injury, the system might attribute a part of the current impairment to the pre-existing condition. Therefore, the worker’s overall condition may include a partly pre-existing condition, which could decrease their workers’ compensation disability benefits.
For example, say a worker had back surgery five years before taking a job. The surgery resulted in a 10% loss of mobility. They can still perform their job adequately despite lingering back pain after the operation. One day on the job, the individual falls and suffers a serious back injury.
This worker had a pre-existing back injury, which was aggravated by a workplace accident that left the worker temporarily disabled.
As long as the worker has not lied about the prior back problem or tried to hide it from their employer, the injured worker may be entitled to workers’ compensation for the new injury. This includes payment of medical expenses and replacement of a portion of lost wages while the employee cannot work.
Even though the current injury’s precipitating event – the harm to the back caused by the slip-and-fall accident – resulted in a more severe injury because of the pre-existing back condition, the worker’s current condition should still be attributed to an injury during the course of employment. That makes it eligible for workers’ comp.
The employer or insurer might argue that a portion of the treatment the worker is receiving is for their pre-existing back condition. They could argue that the recent workplace slip-and-fall accident didn’t actually cause an injury, and the worker is using the recent accident as an excuse to get workers’ comp insurance to pay for procedures the worker had put off.
A workers’ compensation insurance company cannot legally deny medical care and wage-replacement payments solely because a work-related injury aggravated a pre-existing condition. However, the insurer may seek to withhold a portion of a final settlement. Negotiations may be required to reach an appropriate workers’ compensation settlement agreement. A workers’ compensation attorney who knows what the law provides can be a strong advocate for you in this situation.
Pre-Existing Injuries and Permanent Disability Benefits
Once a patient receiving workers’ compensation reaches MMI, if the patient has not fully returned to her pre-injury status, she receives a permanent impairment rating expressed as a percentage of disability.
A worker who has a permanent medical impairment is entitled to permanent partial disability benefits if they can return to work, even if it’s the same job with no restrictions. A worker who cannot return to working for a living may be entitled to permanent and total (P&T) disability benefits.
A commissioner with the S.C. Workers’ Compensation Commission would determine the amount of permanent disability benefits in a hearing. This decision is based on a variety of factors, including the worker’s prior wages, age, education, and work experience, as well as their impairment rating.
In this hearing, the insurer could argue that the worker’s current disability is partly due to a pre-existing injury and the permanent disability benefits should be reduced accordingly. They would likely present testimony from the physician assigned to the case, who might say, for example, 25% of the worker’s current condition is due to the pre-existing back injury.
To preserve your full benefit, you would need to present evidence that supports your claim. A Joye Law Firm workers’ compensation attorney may refer you to a medical care provider who understands South Carolina’s workers’ comp system for an exam and second opinion. The exam could supplement your medical record. Our knowledgeable North Charleston work injury lawyers can help you gather and present evidence about the nature and extent of your debilitating injury.
Common Causes of Pre-Existing Conditions
A pre-existing condition is a medical complication that existed prior to a workplace accident that affects the same part of the body as the older injury.
Some pre-existing conditions likely to be re-injured or exacerbated in a workplace accident include:
- Herniated disks
- Spine degeneration
- Sprains and strains to back, legs, knees, ankles, arms, shoulders, wrists, hands
- Carpal tunnel syndrome
- Torn ligaments
Any kind of blunt-force injury or stress and strain encountered at work may exacerbate a pre-existing injury. Here are some plausible examples:
- A manufacturing plant worker injured his ankle in a bicycle accident a few years ago. Following medical care, his ankle still aches sometimes, but he can live with it. One day at work, a piece of machinery falls on his foot and aggravates the old ankle injury so badly he is now on crutches and needs surgery.
- An office worker had surgery after tearing ligaments in her wrist while playing with her children. Years later, the wear and tear of her job duties – data entry, typing, using a computer mouse, and sorting mail deliveries – have exacerbated the pain in her wrist.
- A store clerk manages his arthritis with medicine and regular exercise. He trips and falls while at work, hitting his hip against a table’s edge and then falling to the floor. This has inflamed his arthritis so badly he cannot return to work, even though the injuries he suffered from the fall have healed.
In all of the above cases, we would expect that the injured worker has a valid claim for workers’ comp benefits.
How to Support Your Pre-Existing Injury Claim
- If you have had a prior injury that continues to cause you problems or any level of disability, your employer should know about it if you applied for the job after the injury was sustained. Failure to honestly answer questions about pre-application injuries could result in a “fraud in the application” defense being asserted in your workers’ comp case. If you are required to undergo a physical prior to new employment, you should advise that doctor of any previous injuries you have had.
- If you suffer a new injury at work, notify your employer and request medical care. The S.C. Workers’ Compensation Act requires you to notify your employer at the time of the accident, or if you were incapacitated, within 90 days of the accident in most cases.
- When you see a doctor, explain your pre-existing condition to him or her if it is relevant. Explain what your work-related injury has done to worsen your pre-existing condition. Describe how the two injuries and their impact on you are different, such as different levels of pain or different limitations on mobility.
- As with all workers’ compensation claims, follow the orders of the physician in charge of your medical care. This includes going to all follow-up appointments for treatment, attending rehab, and taking medications as prescribed. Failure to do so can jeopardize your claim.
- Contact an experienced workers’ compensation attorney if there is a dispute about your benefits. Claims that involve pre-existing injuries are the more easily challenged and often the most complex to settle appropriately. It is quite likely that you will go without the benefits you deserve or otherwise leave money on the table if you do not have qualified legal representation
Contact Our S.C. Workers’ Compensation Attorneys
Our North Charleston workers’ compensation attorneys at Joye Law Firm will work to make sure your pre-existing condition is not used as an excuse to deny the workers’ comp benefits you need.
Joye Law Firm has been helping injured workers in South Carolina for more than 50 years. We have offices in North Charleston, Columbia, Clinton, Myrtle Beach, and Summerville. We represent injured workers throughout South Carolina.