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Pre-Existing Conditions

Last modified: Jul 16 2021

What is a pre-existing condition under workers' comp?

A "pre-existing condition" simply means that had some prior medical issue with the body part that you injured at work. Although pre-existing conditions are covered in Georgia, the insurance companies fight these cases very hard.

If an employment injury aggravates a pre-existing injury to the point where medical treatment is required, or if the employment aggravation of a pre-existing injury disables the employee from working, the employee will be entitled to workers’ compensation benefits. However, he is only entitled to workers’ compensation benefits as long as the employment aggravation continues.

It is your burden to show that the accident at work aggravated your pre-existing condition. In other words, the accident either made the pre-existing condition worse or caused it to flare up. This is usually not a very difficult standard to meet. Most of the denials we see for pre-existing conditions are based on very weak evidence. However, insurance companies will often deny valid claims because they hope you will give up instead of hiring a Georgia workers' comp attorney.

The workers’ compensation insurance can only deny a pre-existing condition if it is completely unrelated to your work accident.

How the insurance company tries to deny your claim as pre-existing

First, they try to get you to sign medical releases and dig into your medical history. They usually do this by getting you to sign a blank medical release. Then they can send out dozens of medical records requests and they don't even have to tell you about them. You should never sign a blank medical release. I have even seen unethical insurance companies request gynecological records when the injured worker has a back injury. I also commonly see the insurance company request chiropractor records for injured workers who have a back injury. They will try to use chiropractor records from many years before the accident to try to claim all your problems are pre-existing.

Signing a blank medical release can give the insurance company ammunition to try to deny your claim. I never let my clients sign a blank release. The name of the medical provider must be listed on the release. You are only required to give them a medical release for medical treatment related to your injury. Otherwise, they will go on a wild goose hunt looking for medical records that could be used to deny your claim. Never sign a blank medical release that does not have the provider listed.

They may also try to send you to an independent medical examination. There's nothing "independent" about this examination. The insurance company selects the doctor and pays them up to $1,200 to create a report on your case. This doctor will probably never see you again. His job is to help the insurance company. If the insurance company sends you to an IME, this is usually an indication that they want to cut off your benefits.

Example of Insurance Company Tactics

An injured worker hurts his shoulder at work. He is pushing a cart and feels his shoulder pop. There is a burning pain. He never experienced any shoulder pain prior to this injury. He sees an orthopedic doctor who recommends a rotator cuff repair surgery. But, an MRI scan shows that there was some prior damage in the man's shoulder from before the accident. The insurance company denies the claim because of the MRI scan.

Is this worker entitled to receive medical benefits?

Yes, he can still get workers compensation to pay for the surgery if he can show that the work injury caused his symptoms. If the workplace injury caused some hidden problem to become symptomatic, then workers compensation insurance is 100% on the hook to pay for his benefits. It does not matter that he did not have a perfect shoulder before the accident.

The insurance company denied my claim as pre-existing. Now What?

You need to file a hearing with the State Board of workers' Compensation and request medical benefits. You will need medical evidence that proves your work accident aggravated the pre-existing injury. An attorney will be able to help you gather this evidence. I have personally helped hundreds of injured Georgians get compensated for so-called "pre-existing conditions".