Building on our recent article about the basic elements of claim validation in the Washington workers’ compensation system, let’s explore a subject that can be particularly frustrating for employers: pre-existing conditions.
Understanding Pre-Existing Conditions in Workers’ Comp
Pre-existing conditions can complicate the assessment of workers’ comp claims by worsening the severity of an injury or blurring the line between work-related injuries and prior medical issues. However, regardless of the worker’s physical condition at the time of injury, a pre-existing condition doesn’t disqualify the worker from having a new, allowable claim. This means that an employee who’s had a bad back for years, for example, can have an allowable claim for a back injury that occurred at work. It can seem unfair to feel like you’re paying for an injury that existed before the employee started working for you, but if their condition worsened from an incident at work, then it’s an allowable claim.
Advocating for Fair Claim Costs in Complex Cases
Even if an employee with a pre-existing condition has a valid claim, there are actions your claims manager can take to help move the claim along quicker or prevent you from being held responsible for medical conditions beyond the scope of the work-related injury. L&I will request prior medical records for that employee to determine the baseline of their condition; your claims manager can also review those records to ensure L&I has appropriately considered the prior medical information when evaluating the current claim. Thoroughly reviewing this information helps your claims manager ensure that you’re not held responsible for treating a medical condition beyond the injury caused by the work-related incident. Take the example of an employee who has had a bad back for years: the workers’ comp system is designed to get them back to the medical state they were in prior to the on-the-job injury, not to completely heal their chronically bad back. Your claims manager can advocate on your behalf to ensure the claim costs only cover what it takes to treat the worker for the injury caused at work, but not beyond.
Tips: Although employers are restricted from asking certain questions about pre-existing medical conditions during the hiring process, HR professionals play a vital role in mitigating the impact of pre-existing conditions on workers’ comp claims. You should provide candidates with a complete job description including the physical demands of the work, with the understanding that they will need to perform those physical functions (with or without reasonable accommodation). If you have positions that are particularly demanding, consider whether a functional capacity evaluation (FCE) should be part of the hiring process. An FCE is performed by a qualified and licensed physical or occupational therapist and must be validated to ensure you are not discriminating against individuals with disabilities. If you a Vigilant member and are considering implementing an FCE prior to allowing an employee to start working for you, you should review our Legal Guide ADA: Medical Inquiries and Exams of Applicants and Employees and talk with your assigned Vigilant claims manager and Vigilant Law Group employment attorney before moving forward. Even if you take these steps, it’s inevitable that you’ll eventually have a valid workers’ comp claim with pre-existing conditions present. When that happens, don’t despair; if you participate in Vigilant’s workers’ compensation program (Retro or claims management), your assigned claims manager will do everything they can to ensure you’re not on the hook for more than you should be.
Pre-existing conditions may complicate workers’ comp claims, but you don’t have to face them alone. Connect with us today to ensure you’re protected and paying only what’s fair.
