Pre-existing conditions can be a big concern for work injury claimants. Many workers worry that pre-existing conditions will prevent them from getting L&I benefits. This is a reasonable concern. After all, pre-existing conditions can complicate your L&I claim.
What are pre-existing conditions in workers’ compensation claims?
A pre-existing condition is a condition that a worker already has, before a work injury or occupational disease. Furthermore, it can be a physical condition or a mental condition. There are many types of pre-existing conditions. For example, common pre-existing conditions include:
1) A congenital condition that existed since birth
2) Accidents or injuries during childhood or adolescence
3) Past injuries that happened outside of work
4) Many conditions that arise from the natural aging process.
Work injury and pre-existing conditions
The Department of Labor and Industries (L&I) oversees workers’ compensation claims in Washington State. After a work injury, L&I sometimes uses pre-existing conditions to deny medical coverage. However, Washington State law provides protection for work injury claimants. In fact, certain sections of the law specifically address pre-existing conditions after a work injury. Under the law, the workman’s comp legal system protects workers with pre-existing conditions in two ways:
a) Disability: L&I must consider pre-existing conditions when they evaluate your overall disability; and
b) Aggravation: Sometimes, a work injury or occupational disease aggravates pre-existing conditions. In such cases, L&I must take responsibility for aggravated pre-existing conditions.
We take the work injury claimant as we find them
When a work injury happens, L&I must accept injured workers as they are. Funnily enough, there’s a saying among worker’s compensation professionals: “We take the injured worker as we find them”. This phrase can be a bit confusing. Let’s explain what it means.
When claim managers handle an L&I claim, they must evaluate the long-term impact of the industrial injury. During their analysis, L&I has to consider the worker as a whole person. In other words, future-looking analysis and disability evaluation must include pre-existing conditions. In fact, L&I’s analysis may combine pre-existing conditions with new ones that arise from the work injury. This is a requirement under the Industrial Insurance Act in Washington State.
To simplify things, let’s review some examples. After a workplace injury, say that new medical conditions do not show total disability. However, if you combine pre-existing conditions with the new ones, then together they result in temporary total disability. Hence, the law entitles the worker to temporary or total disability benefits. Another name for this L&I benefit is time-loss compensation. In workers’ compensation, we call this “combined effects” of pre-existing and claim-related conditions.
Aggravated pre-existing conditions in an L&I claim
Another important aspect of L&I claims is aggravation of pre-existing conditions. Here, a work injury can activate or aggravate pre-existing conditions. Consequently, L&I must take responsibility for these pre-existing conditions. But, before going over the details, let’s first talk about symptomatic vs asymptomatic conditions.
At the time of the work injury, a certain medical condition may be symptomatic or asymptomatic. A symptomatic condition refers to one that produces symptoms. Also, a condition is symptomatic if it’s disabling or needs treatment. Symptomatic conditions can be a combination of all three of these effects. Or, a condition is asymptomatic if there are no symptoms. In other words, if it’s not disabling and the person doesn’t need treatment.
A workplace injury may “light up” or activate a pre-existing asymptomatic condition. In such cases, L&I must provide coverage for the pre-existing condition. Similarly, a work accident can worsen or aggravate pre-existing symptomatic conditions. For those, L&I needs to cover the conditions under the L&I claim. In addition, the law acknowledges there may be more than one cause for a condition. Similarly, more than one cause can activate or aggravate pre-existing conditions. However, for L&I coverage, it’s enough to show that the work injury is one of the causes.
How to take advantage of pre-existing condition legal protections
Many people have pre-existing conditions before they suffer a work injury. If you are one, then it’s important to follow the 2 recommendations below:
i) Admit that you have pre-existing conditions (if you know of them); and
ii) Describe your conditions and any symptoms caused by the industrial injury. Here, you must explain how the new symptoms are different than before.
These steps can be very confusing. Let’s talk about them in greater length below.
Disclosing pre-existing conditions after a work injury
You cannot hide pre-existing conditions. It never works. Don’t waste your time trying. If you try, it’ll create bigger problems later in your L&I claim. So, it’s very important to be open and honest. Tell your L&I doctor about your pre-existing conditions. If your conditions were symptomatic before the work accident, then let your doctor know. Also, if you didn’t have symptoms before the work injury, then tell your doctor. It’s important for the doctor to know everything from the start.
Sometimes, L&I may ask for a list of providers that have treated you for the conditions. If they ask for the list, then you must give it to them. The list and your treatment history will assist L&I and your treating providers. With it, they can determine if your pre-existing conditions impact your workplace injury and how. Also, it’ll be easier to consider pre-existing conditions when the decide your L&I benefits.
Pre-existing conditions before and after the work injury
Let’s say you have symptomatic or disabling pre-existing conditions. Here, it’s very important to describe your conditions as they were before the injury. Next, it’s equally important to explain how they changed because of the work injury. You must describe the conditions accurately and in detail.
Personally, I often recommend my clients to practice describing the conditions with family and friends. On top, I recommend writing down everything you remember about the condition before and after. Finally, think if your friends or family members saw your symptoms. If so, have them write down what they saw prior to the injury. Also, ask them to document what they observed after the workplace injury.
What happens if L&I doesn’t cover pre-existing conditions?
For some, a work injury doesn’t impact pre-existing conditions. In such instances, L&I won’t take responsibility and won’t provide coverage. For example, let’s imagine you have pre-existing migraines. Your industrial injury doesn’t activate or make them worse. Thus, L&I won’t take responsibility for your migraines. Furthermore, the migraines weren’t activated or aggravated. Therefore, there’s probably no legal action you need take if L&I denies benefits for these migraines.
However, L&I does need to consider the “combined effects” when assessing your total disability. They must consider your migraines together with your L&I claim conditions. Unfortunately, L&I sometime ignores pre-existing conditions when performing total disability evaluations. This is a red flag. If this happens, it’s important to speak with a workers’ compensation attorney or L&I attorney.
Secondly, L&I may deny pre-existing conditions when they think they’re congenital. Other times, L&I will blame certain conditions on aging. Most commonly, we see this happening with degenerative conditions. Many medical diagnostic tests show arthritis and neuropathy. Other exams reveal muscle and cartilage tears. Sadly, L&I often concludes that these conditions are not related early in the L&I claim process, without proper diagnostics.
IME exams and pre-existing conditions
Almost always, L&I will schedule an Independent Medical Examination (IME). Unfortunately, I can tell you the IME outcome ahead of time. Most likely, the IME exam will say that: (1) The pre-existing conditions weren’t caused by the work injury; and that (2) they were not activated or aggravated by the workplace accident.
When this happens, you must provide L&I with a different medical opinion. For that, it’s best to have an attending provider (AP) who’s a strong advocate. Your L&I attending provider can (and should) review the IME report. The attending physician may also provide a non-concurring opinion to L&I on their own. However, not every work injury claimant has a caring attending provider. If you don’t have one, it might be best to call a workers’ compensation attorney. Many good L&I lawyers can help address this issue.
Summary and final comments
To summarize, pre-existing conditions can complicate workers’ compensation claims. Yet, work injury claimants don’t need to worry if they have pre-existing conditions. The law in Washington State provides many protections. Workers can take very simple steps to take full advantage of these protections. On occasion, pre-existing conditions may cause problems in L&I claims. When those arise, it’s important to consult with a workers’ compensation attorney.