Employees may receive workers' compensation benefits in situations where they can demonstrate an injury was work related. Sometimes, however, an injury has more than one cause. An employee may already be suffering from a medical condition, and his job duties may make that condition worse. When this happens, it can become more difficult to determine if the employee is going to be able to receive work injury benefits.
Safety News Alert recently reported one complicated case in which the employee was forced to appeal an initial denial of benefits when his job duties resulted in a more serious medical problem than he had previously had. The case is an illustration of the wide range of situations where an employee may get benefits despite already being affected by an injury. It also demonstrates the lengths insurers may sometimes go to in order to avoid paying benefits an employee should be entitled to receive.
Workplace Injuries Resulting in Exacerbation of Pre-Existing Conditions
The case reported on by Safety News Alert arose when an employee, who loaded and unloaded trucks for a living, slipped and fell while on a truck. His treating physician indicated the fall had caused an acute injury to his hip. As a result of the acute injury the employee sustained, he was unable to put weight on his leg and he needed a hip replacement procedure. He sought workers' compensation coverage, so workers' comp medical benefits could pay for his surgery and so he could receive temporary total disability benefits while he underwent and recovered from the procedure.
The problem is, he had already suffered from necrosis of the hip and a hip replacement procedure had been recommended by his doctor before the fall occurred on the truck. The employer's workers' compensation insurer had him examined by a doctor, who said the fall had not caused any lasting or permanent impairments. The claim was denied because the insurer believed the pre-existing hip damage precluded coverage.
The employee appealed to the workers' compensation commission. He had previously been asymptomatic despite his joint problems, but the fall had caused his hip problems to be so bad he was unable to stand without pain. He had hoped to continue working as long as possible before getting the surgery, and the fall made this impossible. He presented information from his treating doctor and testimony from an orthopedic surgeon who said the fall significantly exacerbated the damage to the hip.
The worker was successful in his appeal. Although the insurer took the case through two additional levels of appeal trying to overturn the grant of benefits, the insurer was ultimately unsuccessful when the state court ruled on behalf of the employee. Because his work injury had exacerbated the hip problems he already faced, the surgery should be covered and he should receive disability income. Other employees who experience similar exacerbations of existing conditions should be aware they too may have the right to benefits coverage, although they may need to fight for it.