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Workers’ Compensation And The “Pre-Existing Condition” Denial

Pre-Existing Condition. It’s one of the most common excuses used by insurance companies to deny workers’ compensation claims. And, the excuse is often wrong.

Our office regularly receives calls from people who have been (wrongly) denied benefits based on the excuse of a “pre-existing condition.” The injured worker usually had some pre-injury health problem the insurance company seized-upon to deny his or her claim. Remember, most people don’t have perfect health. And, our workers’ compensation system was not designed to help only those few people with perfect health.

So, what does Alabama’s workers’ compensation law say about prior health problems? How does our law define pre-existing disabilities? Can pre-accident health conditions affect a claim? These are good questions.

Here is the legal principle stated by our Court — “If the previous injury has not demonstrated itself as disabling and has not prevented the employee from performing his job in a normal manner, then the previous injury will not disqualify the claim.” Oberkor v. Central Alabama Home Health Care Services, Inc., 716 So.2d 1267 (Ala.Civ.App. 1998). In other words, the primary question in considering whether or not a prior health condition limits a workers’ compensation claim is — Did the prior condition prevent the employee from fully performing his job in a normal manner?

I’ve addressed this issue in cases more times than I can count. Unlike many lawyers who don’t really go to court, I have tried numerous cases on this issue. And, I’ve addressed the issue on appeals to the Alabama Supreme Court. While some lawyers don’t understand the significance of this legal principle, it is important to the investigation of many cases. Maybe a worker suffered some periodic back pain prior to his or her work-related accident. Maybe a worker suffered some joint pain or spine degeneration prior to his or her work-related accident. Again, how many adults don’t suffer periodic problems? How many working age adults were in perfect health before their accident? Almost every adult suffers some degeneration in their spine. The issue is whether or not this prior condition impacted the worker’s ability to perform the full duties of the specific job upon which he or she was hurt at the time of the injury. For the current injury to be compensable, you must show it contributed to the worker’s condition.

On many occasions the insurance company’s denial is flat wrong. How do we combat these wrongful denials? We don’t ignore the excuse like many lawyers. We prepare our cases for trial under the assumption the insurance company’s excuse must be met head-on. We do several things:

  • We interview our client extensively to gather full information about his or her job performance. The injured client needs to understand their past job performance is important. It’s important in demonstrating he or she could previously perform the job fully. It’s also an important part of the worker’s life story that needs to be told in court.
  • We seek our client’s complete personnel file and any other employer documents available. Why are these documents important? I’ll tell you a case story as an example. Years ago, I represented a client who suffered a back injury while lifting heavy bathtubs in a local plant that manufactured plumbing fixtures. Yes, this worker did have periodic pain flare-ups prior to his work-related accident. He had even undergone some periodic physical therapy for flare-ups. We obtained all our client’s time sheets and payroll records. Those records revealed he was working 80+ hour weeks for months prior to his accident with no accommodations and no absences. He was working fully and performing the job of two normal employees. We easily defeated the insurance company’s pre-existing condition defense.
  • We cross-examine the boss using his own pre-accident statements. In workers’ compensation cases, we will often cross-examine the injured worker’s boss. Even in cases where the insurance company is wrongly arguing a pre-existing condition, many bosses will honestly admit the worker was doing his or her job fully prior to the accident. Yet, before we ask the question, we look for documents like annual reviews. Documents like annual reviews are great since they often show a worker who was capably and fully working prior to the accident. And, these reviews are usually completed and signed by the boss testifying.
  • We locate co-workers who can testify to our client’s work habits. In some cases, co-workers can provide key testimony demonstrating the client was working fully prior to his or her injury.

Why do our workers’ compensation laws define pre-existing conditions in terms of their effect upon work? The answer is simple. Workers’ compensation benefits are limited. They are designed to provide medical treatment and rehabilitation in order to return injured workers back to work whenever possible. They are designed to help all workers in our community rather than the few in perfect health.

My advice. Don’t accept a denial of your workers’ compensation claim without consulting legal counsel. And, don’t just call any attorney. Many attorneys fail to understand the unique issues in our workers’ compensation laws. Do some research to find an attorney in your community who has experience fighting insurance companies for his or her clients. Whether your case involves a workers’ compensation claim, automobile accident injury, or some other type of injury, do your homework before hiring a lawyer. Your decision can make a huge difference in your case.