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Reporting Preexisting Conditions: A Model

This is the third in a 3-part series on preexisting conditions.

If your patient’s work injury has combined with a preexisting condition, your opinion on whether the work injury caused 51% or more of your patient’s disability or need for treatment (“major contributing cause”) may determine whether your patient receives Workers’ Compensation benefits. How should you address this question?

We want to give you an example of how a local physician handled this question, but first let us review. What is a “preexisting condition”?

As reported in the first article of this series (Vol. 3), Workers’ Compensation law in Oregon defines “preexisting condition” as:

“…any injury, disease, congenital abnormality, personality disorder or similar condition that contributes or predisposes a worker to disability or need for treatment and that precedes [the claimed injury].”

If your patient who suffered a work injury, has such a condition and his/her work injury has combined with this condition, the causal role of the work injury (as compared to any and all such conditions) must be 51% or more in order for the worker to be eligible for workers’ compensation benefits.

A local worker was injured in an auto accident while working. For many months after the injury, she suffered and was treated for right sacroiliac discomfort into her right buttock. X-rays showed a congenital abnormality, a pseudo-arthrosis where the transverse process bone joined with the iliac (hip) bone. An independent medical examination team consisting of a neurosurgeon and an orthopedic surgeon found this pseudo-arthrosis to be at the site of the worker’s symptoms. They declared it a congenital abnormality, a preexisting condition which was the major contributing cause of the worker’s need for treatment or disability.

The worker’s treating physician disagreed. When he received a copy of the IME report from the workers’ compensation carrier, he checked the “I do not concur” box and enclosed the following letter:

I cannot concur with the IME report done on [patients name] I believe the major contributing cause for her present need for treatment and/or disability, is not the congenital anomaly itself, but the injury to the congenital anomaly that was caused by the motor vehicle accident she was involved in. The congenital anomaly is a preexisting condition, but prior to the accident she was not having the disability she has now, nor the subjective pain complaints at the site of the congenital anomaly. Therefore, her current level of disability and need for treatment is due to the injury to that particular area of her body.

She states that she has had a reduction of pain of about 80% since the time of the accident, however, that still leaves her with 20% pain symptoms and these are directly related to injury caused by the accident, even though it was injury to a pre-existing condition.

If you have any questions, or need further clarification, please feel free to contact me.

The IME doctors’ opinion was that the congenital anomaly predisposed this worker to this injury and caused 80% of her need for treatment. This opinion directly contradicted the opinion of the attending physician.

In such circumstances, the judge will base his/her decision on the opinion of the attending physician if the attending physician persuasively explains the nature of the injury treated, as well as the nature of the alleged “preexisting condition,” and presents the comparative causal contribution of each.

In short, as treating physician you should explain thoroughly the causal roles of both the injury and any and all preexisting conditions, in a way which supports your opinion as to the extent (percentage) each contributes to your patient’s disability and/or need for treatment. This will give the judge all he/she needs to rule on the compensability of your patient’s injury.

This article was prepared by Arthur W. Stevens, III

Posted in: Workers' Compensation Lawyer Articles