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handicap_cracks_somadjinnClaims with comorbidities create some of the most difficult challenges claims examiners face. In workers’ compensation, comorbidities refer to those existing medical conditions that impact a person’s primary work-related injury. Such conditions often impede a worker’s ability to recover or be healed from the stated injury.

In California, employers are required to pay for medical care for a worker’s comorbidities when the pre-existing conditions are slowing the injury in question. While requirements vary from state to state, all employers should be aware of the impact comorbidities can have on claim costs and contemplate ways to deal with them. To handle these claims appropriately, claims examiners and the defense counsel they employ must stay abreast of current case laws and peer-reviewed medical literature. Every workers’ compensation claim has unique sets of facts and medical nuances.

Several examples readily illustrate these concepts:

Diabetes – a restaurant worker with diabetes received a laceration on his left foot after an industrial-size can fell from the top shelf in the storage room. Diabetes, in turn, slowed the healing of his foot and prevented maximum medical recovery on a timely basis. The employer can be responsible for treating diabetes in order for the foot to heal, notwithstanding the fact that the diabetic condition may have pre-existed the injury.

Obesity – a hotel housekeeper experienced a back injury from turning a mattress in one of the guest rooms. Her back condition would not heal because of her obesity. The employer may be responsible for expenses associated with a weight loss program so that she can recover from the back injury.

Heart condition – a store clerk suffered a knee injury when he slipped and fell on a wet surface area while mopping the floor. The injured knee required orthopedic surgery. The employer could be responsible for paying for additional medical care to ensure his heart condition would withstand the orthopedic surgery.

Psychological condition – a convenience store clerk suffered a psychological condition from an abusive domestic situation that ended three years ago. During a late shift, the store clerk was robbed at gun point. The ensuing scuffle resulted in torn shoulder ligaments, four broken ribs and a fractured wrist. The employee is also in need of psychiatric treatment due to the traumatic event. The needed care for the pre-existing condition would no doubt complicate recovery from the work-related psych component. The examiner must pay special attention in providing all necessary psychiatric care to cure or relieve the effects of the industrial injury.

While the examples above are hypothetical, one real life example of a case involving comorbidities was the Braewood Convalescent Hospital v. Workers’ Comp. Appeals Bd., 34 Cal.3d 159. The injured worker slipped and fell while he was cooking. The result was an injured back and elbow. The employer was responsible for paying for an out-of-state weight loss program, temporary disability during the program and expenses for future participation. To read more about the case, visit the Stanford Law School website at Braewood Case.

With an aging workforce, we can expect comorbidities to be a complicating factor in a majority of future claims. It is important to work with all stakeholders including the treating physician, injured worker, claims examiner, managed care specialist and other team members to ensure underlying conditions are treated in conjunction with the primary injury at hand.

Comorbidities can also be important in the apportionment of impairment ratings. If an injured worker suffers from a number of pre-existing conditions and the primary condition accounts for a small percentage of the resulting disability, it is important to demonstrate the influence of the other conditions in comparison to the primary injury. The employer’s interest is to have the impairment rating reflect the appropriate percentage of the overall condition.

The claims world is comprised of complex circumstances that lack definition and hinge on extensive interpretation and judgment. How do you think comorbidities will affect workers’ compensation claims in the future and what are you doing to mitigate and manage these conditions today?

Darrell Brown, Chief Performance Officer

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2 Responses to Sedgwick handles complexities and complications associated with comorbidities and claims

  1. Gary Cavazzi says:

    In cases where so-called “concurrent” conditions are potentially linked in a delayed recovery pain patient with a spinal injury or similar condition , one can mitigate or eliminate WC responsibility for unrelated problems [e.g., obesity, arthritis, etc]. The reasoning is straightfoward.

    Neuroscience and population studies show that 80% of chronic lumbar complaints are related to psychosocial reactions by the patient rather than “the spinal injury” itself. In this majority of cases, the concurrent medical problems [which are physical in nature or pre-existing] are not causing the injury-related symptoms.

    If the claimant is properly assessed and the emotional/psychosocial can be shown to be predominant, then appropriate care becomes conservative [i.e., CBT, physical therapy, and judicious medications]. The medical necessity for opioids, surgeries, and anesthetist injections is not only not clinically warranted, it is contraindicated because of increased patient risk exposure. Because concurrent features [e.g., obesity, pre-existing conditions, etc.] increase the risk of aggressive intervention, then conservative care becomes the patient’s best and safest WC treatment option. One treats the painful condition and the other medical problems shift back to general health care.

    The issue for proper management is to make an early and accurate assessment of the delayed recovery patient so that the incorrect link between the pain and concurrent conditions is not made.

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