Any kind of insurance is a double-edged sword, and it often feels like each party is on the wrong side of the deal. Those who have insurance feel like they can't get a break when they need help, and those providing the insurance often feel like everyone has their hand out for everything under the sun. Add into this that a small subset of the population uses a large share of available healthcare resources and that fraud occurs on a regular basis, and you can see why pre-existing conditions make workers' compensation claims trickier. Below are the essentials you should know as an employer.
The Straight Facts
Obviously, you do not want to exclude a capable employee simply because they have a common condition like a heart issue or knee problems. However, disputes can arise when an employee alleges a workplace incident caused their condition.
Legally, an employer is only responsible if work activities materially worsen a pre-existing condition. That shifts the burden onto the employer to show the injury or condition is unrelated to work unless the worker can prove otherwise. For example, if someone has a back condition and you fail to provide reasonable accommodations such as ergonomic equipment, you may be found at fault.
What You Can Do
Documentation is highly encouraged for all employees, and you should be especially careful when hiring or accommodating workers with known medical conditions. Have employees sign acknowledgement forms that describe the steps you've taken to reduce injury risk and to accommodate limitations.
Avoid asking employees to perform tasks clearly outside their capabilities; for example, don't ask someone with a documented knee injury to routinely lift heavy objects if lifting is not part of their job description. For industry-specific policy information, see Clothing, Hat, Umbrella Manufacturing Workers Compensation Insurance. If you're unsure how to document or handle a situation, talk to an agent.
Additional Considerations
Each state has its own rules about how pre-existing conditions affect workers' compensation claims, so follow your state guidelines and consult your insurer when in doubt. If the original injury was unrelated to work or the worker was acting outside a doctor's orders, a claim may be denied.
Be aware that false statements by an employee can create grounds for a fraud investigation and claim denial. For information about specialized coverages that may affect claim handling, see Difference in Conditions (DIC) Insurance.
Frequently Asked Questions
Can an employer refuse to hire someone because of a pre-existing condition?
An employer should not discriminate based on a medical condition unless it creates an undue hardship or prevents the worker from performing essential job duties; follow applicable accommodations and nondiscrimination laws.
If a worker’s condition existed before employment, can they still file a workers' compensation claim?
Yes, a worker can file a claim if work duties aggravate a pre-existing condition, but the employer and insurer may investigate to determine whether the workplace caused a worsening of the condition.
What documentation helps defend against a fraudulent claim?
Accurate job descriptions, written accommodations, signed acknowledgements, incident reports, and medical records can all help establish whether work contributed to an injury.
When should an employer consult their insurance carrier?
Contact your insurer promptly after an incident or when you learn of an injury so the carrier can advise on claims handling and any state-specific requirements.