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Aggravation, pre-existing condition, new claim, or someone else’s problem?

Affida is successful in having a claim declined where there was no incident

When an injury occurs the initial determination is wether employment was a substantial contributing factor. Even if this is ascertained one also needs to assess if the injury is a result of a frank incident (i.e. something actually occurred), an aggravation or a continuation of an underlying condition.

When it comes to pre-existing conditions an Agent on many occasions simply accepts the claim without fully investigating the circumstances even when an employer raises concerns. Unfortunately it does come down to an employer or someone like Affida to be forceful enough with an Agent to ensure that these matters are fully investigated.

In a recent case, Affida was referred to a claim where an injured worker had suffered a lower back injury after only working in an administrative role for just over six months. The claim had only just been accepted despite concerns raised by the employer. Affida was able to ascertain that there had not been a frank incident. The back pain had started whilst the worker was at work and had gradually got worse. The worker complained about the pain some four months into the job but did not go down the Workers Compensation path at that time. Prior to Affida being involved the employer had the workers work station assessed and some minor adjustments were made. The pain became unbearable and at the six month mark the claim was submitted.

Affida looked into the matter and asked that the Agent arrange an urgent Independent Medical Assessment based on the fact that the treating doctor was not responding to questions being put to him. The treating doctor had been the worker’s doctor for many years so a request was also made for his clinical notes. When the results came back the Independent report stated that there was major pre existing pathology and the current symptoms were not contributed to by the current employment. The clinical notes suggested that the worker had been suffering from this back injury for many years and the condition had never fully resolved. Based on this information further liability was declined in relation to this claim and the case was able to be closed prior to renewal of the policy.

Not all cases end so well but a full investigation of the facts including a factual investigation when there is an incident is absolutely vital. On occasions a worker may have an underlying condition that has been aggravated at work as a result of a frank incident. In these circumstances an investigation should be undertaken in order to ascertain how long the aggravation will last for. Unfortunately the employer is liable for the aggravation but the aim of the investigation is that the employer does not end up being liable for the underlying condition as part of the claim.

It is important that an employer provides all information in relation to the injured worker, including how the injury occurred, when it was reported and if there had been any mention of the injury prior to the claim being submitted. If available, details of the workers past employment may also assist.

To see the services offered by Affida and how they may be able to help you, please visit our Dedcate pageAffida – Workplace Insurance

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