A pre-existing condition can be a vague and scary term. Many people are familiar with the term as it applies to healthcare, where insurance companies often seek to eliminate these conditions from their coverage to save money. But what is a pre-existing condition? What effect will one have on your Ohio workers’ compensation claim? Here, we take a look at pre-existing conditions and offer helpful information that can ensure you and your family are able to obtain all the benefits you deserve after a work injury.
What Is a Pre-Existing Condition?
As it applies to the workers’ compensation world, a pre-existing condition is a medical condition that an injured worker had prior to sustaining a work-related injury. This can include a wide range of injuries and diseases, from arthritis to tendonitis and include conditions that may or may not have been symptomatic. Pre-existing conditions are typically not covered by the Ohio workers’ compensation system unless impacted by a work injury.
Ohio Law and Pre-Existing Conditions
While a pre-existing condition is not covered in many circumstances, there are certain situations in which workers’ compensation will provide benefits to address these issues. They are:
- The pre-existing condition is affecting the care or outcome of an allowed injury. This is known as a co-morbidity condition and occurs when the pre-existing condition must be addressed in order for the worker to recover from a work-related injury. In such situations, the pre-existing condition can be treated until the work injury has resolved.
- The pre-existing condition is “substantially aggravated” by a work injury or incident. The worker experiences an onset of problems pertaining to or a worsening of existing issues concerning the pre-existing condition because of a work injury.
Understanding Substantial Aggravation of a Condition
Prior to 2006, Ohio courts held that “aggravation” of a pre-existing condition could be demonstrated simply by an increase in symptoms that resulted in medical treatment. The injured workers’ testimony that the condition was more painful and his/her actions in seeking treatment for the condition typically satisfied workers’ compensation requirements. Now, a different standard applies. To obtain benefits for the worsening of a pre-existing condition, workers must show that the injury was “substantially aggravated.” It sounds the same, right? How much of a difference can it make?
Quite a bit, as it turns out....
Legally, the terms spell a much different story for injured workers. The addition of the word “substantial” has significantly increased the burden on an injured worker. The law requires that a “substantial aggravation” be documented by objective diagnostic findings, objective clinical findings, or test results, not merely an increase in symptoms alone. This means that medical providers and injured workers must offer tangible evidence showing that the condition has worsened, typically by measurable changes in the condition such as swelling, positive orthopedic or other objective findings, etc. EMG testing, for example, can verify the presence of radiculopathy, a radiating pain that may result when an injury causes a previously dormant condition to become symptomatic. In situations where a pre-existing condition may have been worsened by an injury, it is important to obtain and present evidence of diagnostic testing (or the lack of such testing) that may have preceded the work injury. However, contrary to what employers often try to argue, changes on an x-ray or MRI are NOT required to prove substantial aggravation.
The Standard of Proof and Ohio’s Workers
Substantial aggravation issues often arise where there is evidence of pre-existing degenerative conditions, such as degenerative disc disease or degenerative arthritis. These injuries and conditions can be especially pertinent for those who work in:
- Shipping and fulfillment
The repetitive or load-bearing nature of these types of jobs leaves employees more vulnerable to recurring injuries and aggravation of pre-existing injuries.
The forms of proof necessary can vary given wide range of potential injuries in a great variety of professions with their own unique demands, as well as the medical conditions involved. However, it is not like criminal courts where proof is required beyond a reasonable doubt. Again, conditions may have been previously asymptomatic or causing only minor inconvenience; if the work-injury causes them to become a significant issue associated with measurable, observable limitations, the standard of proof has likely been met.
Pre-Existing vs. Recurring Injuries
At this point, a distinction must be made between recurrence of a condition and aggravation of a pre-existing condition. Fortunately, many recurrent injuries, such as a low back sprain or strain, heal within 8 to 12 weeks of the injury (at least, that is what the defense doctors will tell you!). A recurrence of a previously healed injury is not the same as an aggravation of a pre-existing condition. A worker may sustain many recurrent back injuries, each of which can constitute a separate workers’ compensation claim.
Your employer and the BWC may attempt to save money by denying your new claim when you've had a prior claim for the same or a similar area of the body. Why would you want similar injuries to be recognized in separate claims, you ask? Well, the problem for the injured worker is that any compensation received under an old claim is based on wages at the time of the prior claim, not the potentially higher earnings typically associated with a new claim. If you are making more money now than in, say, 1986 when you hurt your back before, you definitely don't want to be paid based upon your 1986 wages!
It is critical if you have been re-injured or experienced a worsening of symptoms that you seek medical care and that you are as upfront as possible with your provider about your previous problems. As much as is possible, share with your doctor:
- Every symptom you experience. Details of your symptoms and problems need to be discussed with your doctors to be included in your medical record, so share all your symptoms and explain how they are worse/different than before. Nothing is too minor to be mentioned.
- All past injuries you have had. Even if they have since healed. It may be difficult to remember every injury you have ever suffered, but it is important to try. Omitting a prior injury may make it appear that you are trying to deliberately cover something up or mislead the BWC. You don't need another reason for them to look at you cross-eyed!
While it may feel daunting, it is possible to obtain benefits despite a pre-existing condition. At Monast Law Office, our experienced Ohio workers’ compensation team has helped many workers and their families secure the benefits they deserved when work conditions led to pain and injury. Download your free copy of The Worker’s Guide to Injury Compensation in Ohio today to learn more about Ohio workers’ compensation laws.