When Can You Add a Secondary Condition to a Workers’ Comp Claim

The human body is a vast network of integrated components, far more complex than any machinery ever devised. When one part of this network is damaged in a workplace accident, the damage will affect other parts of the body as well. Sometimes, the collateral damage heals on its own. Other times, however, it worsens, causing problems that further interfere with the ability to perform work-related functions.

When a worker files an initial workers’ compensation claim after an on-the-job injury or occupational illness, the claim often focuses on a single injury and does not address complications. So, can you add those conditions to the claim later on? Can you obtain treatment and other benefits for the secondary conditions triggered by your accident?

California law on this issue is complicated, so it is very helpful to work with an experienced attorney during the claims process to ensure that you take the right steps to get your conditions fully covered. It is possible to add secondary or consequential conditions to a workers’ comp claim in California, but you must follow appropriate guidelines and submit appropriate documentation to establish the connection to the initial claim.

Secondary Conditions

A secondary condition, also described as a consequential condition, is an injury or illness that was directly caused by either the workplace injury itself or the treatment used to address that injury. These conditions are often caused by actions that overcompensate for an injury, side effects of medication, complications from surgery, or the psychological effects stemming from the injury. Some examples include:

• A worker trips over an unsecured mat and tears ligaments and tendons in the right ankle. Then the pressure of constantly putting weight on the other side of the body causes problems with the worker’s left knee
• Repetitive lifting leads to chronic back pain that confines a worker to bed. Because it is painful to move, the worker remains in the same position for too long and develops pressure sores.
• A worker is prescribed anti-inflammatory medications to address a torn rotator cuff suffered while lifting boxes overhead. Use of the medication causes gastrointestinal ulcers.
• After surgery for a knee injury, scar tissue builds and tightens, leading to chronic pain and limited range of motion, impairing the ability to walk
• Burns from an office fire cause a worker to suffer severe depression and post-traumatic stress disorder

An experienced workers’ compensation attorney will often be aware of the potential for secondary and consequential injuries and ask questions that enable these conditions to be included as part of an initial claim. Sometimes, however, the secondary injuries take considerable time to develop noticeable symptoms or the injured worker does not realize the connection between the symptoms of the secondary condition and the initial injury.

Legal Criteria for Adding a Secondary Condition to an Existing Claim

The insurance company responsible for paying benefits under a workers’ comp claim will actively seek to limit the amount it must expend on the claim. When a worker claims they need medical treatment for additional conditions and that the secondary conditions interfere with the ability to work, the insurance company will argue that the conditions are not connected to the work injury and therefore are not covered.

To get a secondary injury covered by workers’ compensation, it is important to document the condition in a way that meets legal standards. You will need medical evidence that clearly links the secondary condition to the original injury or to treatment prescribed for that injury. Doctors do not automatically provide records and reports that make this causal connection, so it is often necessary to have your attorney work directly with medical professionals to obtain persuasive medical documentation.

Mental health injuries require particular documentation to receive workers’ compensation benefits. When a workplace injury leads to secondary conditions, such as sleep disorders, or to conditions that often stem from other causes or arise as part of the aging process, it may be necessary to prove that the condition has extreme impacts on life in order to receive benefits.

A Successful Claims Process

The claim for a secondary injury is easier to substantiate when new symptoms are reported to the treating physician as soon as possible after the initial injury. That means it is important to communicate about new symptoms with the doctor. Even if the doctor dismisses your concerns, having them on record can strengthen your claim. It is also important to notify the insurance claims administrator or your employer about the new symptoms.

Often, the insurance company will ask that the injuries be examined by a Qualified Medical Evaluator or an Agreed Medical Evaluator. Because these medical professionals will be working for the insurance company, they may be biased. It is wise to consult with your attorney to discuss ways to help ensure that the process produces a fair evaluation of your condition.

To succeed with either an initial claim or an appeal if benefits are denied initially, it is wise to document every symptom and keep meticulous records of medical visits, including all issues discussed during examinations. It may be necessary to file an appeal with the insurance company as well as with the workers’ compensation administrative judges.

The Right Legal Guidance Can Make All the Difference in a Workers’ Comp Claim

Both the process of filing a claim and its outcome are often much more beneficial for workers with the right legal guidance. Insurance companies rely on professionals to find reasons to deny claims so they can maintain high profit margins. It is tough to succeed against that professional negativism unless you have an experienced ally working on your behalf. At the Law Offices of Benjamin Arsenian, we know how to obtain and present the evidence necessary to secure full benefits for an on-the-job injury and the consequences of that injury and resulting treatment. If you are just starting the claims process, need to add a secondary condition, or are appealing a claim denial, we urge you to schedule a free consultation with our team to discuss how we can help. Just call us at 714-400-2000 or contact us online to get started.