The Not So Short Answer
There is a section in the workers' compensation statute that tells us the meaning of a pre-existing condition, but the Courts and the Workers' Compensation Board, through case decisions, is always looking at this issue, so what it actually means changes or evolves over time.
However, the statute's definition depends on the kind of claim involved.
The Pre-Existing Condition and the Injury Claim
For an "injury claim," a pre-existing condition includes any injury, disease, congenital issue, personality disorder or similar issue that contributes to the need for medical care or disability. However, there must be a diagnosis or at least some medical care for these conditions before the on-the-job injury. The big exception here is "arthritis." The term "arthritis" is more a legal term then medical term. Just like pre-existing conditions, there have been court battles over the exact meeting of arthritis in the workers' compensation context.
The bottom line: If you treated for a condition before your on-the-job injury, and it contributes to your need for medical care or disability, then it's a pre-existing condition. Also, if you have the legal definition of "arthritis," then it's a pre-existing condition.
The Pre-Existing Condition and the Occupational Disease Claim
Another kind of claim you can file in Oregon is known as an "occupational disease" claim. Occupational diseases occur over time when you are exposed to some environmental factor at work that causes an issue. For example, hearing loss claims are often occupational diseases because the hearing loss occurs over a long period of time when exposed to excessive noise at work. Carpal tunnel syndrome is a repetitive stress injury that occurs with repetitive grasping and gripping at work over an extended period of time. A pre-existing condition exists in a occupational disease claim if it contributes to disability from work or need for medical care, and preceded the onset of the occupational disease itself.
The "Silent" Pre-Existing Condition: "Arthritis"
Many of our clients approach us with a claims denial that a pre-existing condition is the main cause of our client's need for medical care, or disability from work. However, our clients will tell us they have never treated for any kind of pre-existing condition, and understandably, cannot understand how the claim could be denied.
The main culprit with these kinds of denials is the definition of "arthritis." The general legal definition of "arthritis" in the Oregon Workers' Compensation system is any "inflammation of a joint." Insurance retained doctors will come up with creative definitions of arthritis to find that there is an "inflammation of a joint." The claim of "silent" arthritis is the most common tactic insurer's use to deny claims when our client never experienced pain before their on-the-job injury.
Medical Opinions Are Important
When we handle these kinds of claims, we review all of the medical records carefully, and often consult with treating doctors to find out whether there is a pre-existing condition, and if so, whether it actually combined with the injury event in the first place.
Questions?
If you are facing a claim denial, and want to know your rights, contact us. We can review your file, and let you know where you stand. If we take on your case, the Oregon Workers' Compensation statute allows us to recover a fee only if we prevail.
