Are Pre-existing Conditions Covered Under Workers’ Compensation?

Life can be a school of hard knocks. Accidents happen. Things go wrong. People get hurt. The older you get, the more likely it is that you’ve suffered some sort of injury that resulted in a chronic medical condition. This is especially true if you’re employed, or have been employed, in an industry that is statistically shown to be more dangerous. Then the chances that you’ve suffered some kind of injury that has lasting effects are greatly increased.

It may be your back or neck that give you trouble because of this prior injury. It could be your knees. No matter what part of you is affected, you deal with the condition and do what needs to be done in order to provide for yourself and your loved ones. Most days, you don’t give this medical condition a second thought - that is, until you’re involved in a workplace accident.

That workplace accident may have left you with injuries to parts of your body not affected by your pre-existing condition. It may also have caused injuries to the parts of your body that were already affected by your condition. In either case, you may be wondering how your pre-existing condition will affect your claim and the amount of compensation that you will ultimately be able to obtain.

The short answer is if the on-the-job accident did not make your pre-existing condition worse, then it is likely that your claim and the amount of compensation that you receive will not be affected. However, if your condition was worsened by the accident then the potential complications are greater. In such a case, whether or not you can obtain compensation depends on whether or not your injury is considered “new” under the law.

Aggravation vs. Exacerbation

California’s workers’ compensation laws are specifically designed to provide compensation to workers who have suffered a work-related injury. The issue of deciding whether an injury is work-related involves two questions:

  • Did the injury arise out of your employment?
  • Did your injury occur during the course of your employment?

Generally, an injury occurs in the course of employment if the injured worker was “on the clock” at the time of the accident. An injury arises out of employment if the cause of the injury is related to regular employment duties.

In claims that do not involve pre-existing conditions, the answers to these questions are usually clear cut. The employee was either at work or they weren’t when the injury occurred. The injury was caused by a work related activity or it wasn’t.

In claims that do involve pre-existing conditions, the answers to these questions may be harder to establish. The employee may have been at work when the injury occurred, but the pre-existing condition may have occurred months or years earlier when the employee was at home or was employed by someone else. Similarly, the aggravation of the pre-existing condition may have been caused by a current work-related activity, but the underlying problem may have been the result of a non-work-related activity, or a work-related activity that involved another employer.

California’s workers’ compensation laws deal with this situation by deciding whether an injury that affects a pre-existing condition results in a “new” injury. For example, let’s say an employee has degenerative arthritis in their lower back. While at work, they pick up a box that causes a disc in the affected area of their spine to bulge. As a result, they are unable to work.

Under these circumstances, the bulging disc would be considered a new injury. So long as there is an increase in the amount of disability, a new need for medical attention, or a change in an existing course of treatment, the injury to the part of the body affected by the pre-existing condition will be considered an aggravation. In this case, the aggravation would be covered by workers’ compensation.

However, symptoms that “flare-up” or reoccur are not considered to be a new injury. Going back to our previous example, let’s say that our employee with the degenerative arthritis in their lower back picks up that same box. That action causes their arthritis to become more acute. They are in pain, but are still able to work. Under these circumstances, the acute arthritis would not be considered a new injury. There was no increase in disability and new medical attention was not needed or there was no change in existing treatment. In this case, the injury to the part of the body affected by the pre-existing condition will be considered an exacerbation and would not be covered by workers’ compensation.

How an Aggravation of a Pre-existing Condition Affects Compensation

If your pre-existing condition has been aggravated by an on-the-job injury, you are entitled to file a workers’ compensation claim for your injuries. The medical bills you incurred for treatment of the aggravation of your condition will be paid for by your employer’s insurer. Furthermore, if you are unable to work, you will be eligible for temporary disability benefits. When your physical condition returns to the level that you enjoyed prior to the aggravation and you are able to resume your normal employment, your benefits will end and your claim will be closed.

If, however, your doctor finds that you will never fully recover from the aggravation of your pre-existing condition, you will be eligible for permanent disability benefits. In such a case, a physician will prepare a report detailing your treatment and prognosis. In this report, the physician will apportion your claim by determining what percentage of your present permanent disability is due to the current work related accident and what percentage is due to other factors, including previous on-the-job injuries.

Your current employer will only be responsible for the portion of your injuries that are attributable to the recent accident. As a result, any compensation award you receive will be reduced by the percentage of your injury that was found to be caused by those other factors.