Workers' Compensation Case Report: Combined Condition Denial

Posted on Jan 17, 2015

The Oregon Workers’ Compensation Board recently decided a case involving a “combined condition.” A “combined condition” exists when a pre-existing medical condition "combines" with an on-the-job injury. The term “pre-existing condition” is a legal term more than a medical term, and is limited to conditions that an injured worker treated for prior to his or her on-the-job injury, or “arthritis.” Just like the term “combined condition,” the term “arthritis” is also more a legal term then a medical term.

This case involved a claim for a combined arthritic knee condition.  Initially, the employer accepted a knee contusion, which is a bruise. This means that the benefits due to the injured worker would be limited to treatment of the knee contusion. The injured worker made a claim for a combined condition, claiming that the knee contusion combined with pre-existing knee arthritis. The insurance company accepted that claim, but then decided that the knee contusion was no longer major cause of the combined condition of the knee contusion with the knee arthritis.  In an effort to get additional benefits, the injured worker then filed yet another claim that the work injury combined with the knee arthritis. This was likely due to a recent case that changed the definition of what is considered to be a “combined condition.”

The Board reviewed the evidence, and decided that the denial was appropriate. The Board explained that the pre-existing knee arthritis was already part of a prior accepted claim, and that prevented an additional claim to include the knee arthritis as part of another claim.

The Board also looked that the medical opinions in the case to decide that the accepted condition was no longer the major cause of the combined condition. When this kind of denial is issued, it is called a “ceases" denial. This is because the insurance company must establish that the injury event has ceased to be the major cause of the combined condition (injury event and pre-existing condition). In order for an insurance company to issue this kind of denial, it must show that there has been some change of circumstance to justify or support the conclusion that the work injury is no longer the dominant factor in causing an injured worker’s need for medical care or disability.

Combined conditions denials can get complicated, especially with recent changes in the case law interpreting the workers' compensation laws.  If you have received a denial involving a combined condition, or any other condition, call us at 503-325-8600. We will review your claims file without charge to let you know whether you have any options.