As defined by Healthcare.gov, a pre-existing condition is a health problem that a person already had before their new coverage starts. Pre-existing conditions can be matters of dispute in workers’ compensation claims. The primary issue:
- Who is responsible for an injury if an employee already had a medical condition before the workplace accident?
In this blog post, our Fresno workers’ compensation defense lawyers provide an overview of the key things that insurers and claims administrators should understand about pre-existing conditions and workers’ compensation claims in California.
Defending a Claim for a Pre-Existing Condition: Aggravation vs. Exacerbation
To qualify for workers’ compensation benefits in California, an employee must be injured within the course and scope of their employment. If an employee has a pre-existing injury and suffered no other injury or medical complications while at work, they have no right to claim workers’ compensation benefits. The more challenging cases involve workers who have a pre-existing injury that was (allegedly) made worse by an accident or incident in the workplace. California’s workers’ compensation laws make a very important legal distinction between an aggravation and an exacerbation:
- Aggravation: For the purposes of workers’ compensation in California, an aggravation of a pre-existing injury occurs when an employee’s prior injury/medical impairment is made substantially worse to the point that they require new treatment or a major change in the course of their current medical treatment. Aggravations are covered by workers’ compensation.
- Exacerbation: In contrast, an exacerbation occurs when an employee’s pre-existing injury/medical condition flares up or develops worsening symptoms but does not require new medical treatment or a major change in their current medical treatment. Exacerbations are not covered by workers’ compensation.
Summary: An employee with a pre-existing injury may be entitled to workers’ compensation benefits if they aggravated that injury so severely that new treatment is required. An aggravation is considered a “new injury” in California. However, a worker with a pre-existing injury that merely suffers some worsening symptoms is not entitled to workers’ compensation benefits.
Workers’ Compensation Claims Should Always be Defended on a Case-by-Case Basis
Workers’ compensation claims can be complicated—especially when there is evidence of a pre-existing condition. The specific facts of the case always matter. There should be a careful review of the workplace accident/incident in question, the worker’s current medical condition, and their prior medical records. Taken together, this information can be used to develop the most effective workers’ compensation defense strategy for a particular case.
Consult With Our Fresno, CA Workers’ Compensation Attorneys Today
At Yrulegui & Roberts, our Fresno workers’ compensation lawyers work tirelessly to protect the best interests of our clients. Our firm emphasizes pragmatic representation. If you have any questions about defending a workers’ compensation claim for pre-existing conditions, our attorneys can help. Contact us today or send us a message to set up a confidential consultation. We provide workers’ compensation services in Fresno, Sacramento, Salinas, Bakersfield, and throughout the region.
