Does Workers’ Compensation Cover Pre-Existing Conditions?

If your pre-existing condition has worsened due to work and you’re struggling with a denied claim, contact us today.

Workers’ compensation is designed to provide financial and medical benefits to employees injured or ill due to their jobs. However, many workers wonder: Can you receive workers’ compensation if you have a pre-existing condition?

The short answer is yes, but it depends on the circumstances. Workers’ compensation does not typically cover a pre-existing condition by itself. However, you may still be eligible for benefits if your job aggravates or worsens a pre-existing injury or illness.

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What Is a Pre-Existing Condition?

A pre-existing condition is any medical issue or injury before a workplace accident or exposure. Some examples include:

Back injuries from a prior car accident or strain
Arthritis or degenerative joint diseases
Knee injuries from a previous sports injury or surgery
Herniated discs or spinal problems
Carpal tunnel syndrome from years of repetitive work
Asthma or respiratory conditions

Missouri workers’ compensation law acknowledges that some workers may already have existing health conditions that could be affected by their jobs. However, the key factor in determining eligibility for benefits is whether the work-related activity aggravated or accelerated the condition beyond its normal progression.

Does Missouri Workers’ Compensation Cover Pre-Existing Conditions?

Missouri law allows workers’ compensation benefits when a work injury significantly aggravates a pre-existing condition. The relevant law governing these claims is Missouri Revised Statutes, Chapter 287 (Workers’ Compensation Law) (RSMo 287.020).

According to Missouri courts, a pre-existing condition must have been substantially worsened by work activities to qualify for workers’ compensation benefits. If an injury accelerates the condition beyond its natural progression, you may be entitled to medical treatment, lost wages, and disability benefits.

The “Prevailing Factor” Test in Missouri

To qualify for workers’ compensation in Missouri, you must prove that the workplace injury was the prevailing factor in causing the disability or need for treatment.

Under RSMo 287.020.3(1), the prevailing factor is defined as:

“The primary factor, in relation to any other factor, causing both the resulting medical condition and disability.”

This means that your work-related injury must be the primary cause of your condition worsening—not just one of many contributing factors. Your claim may be denied if your job only slightly aggravated a pre-existing issue. However, benefits may be available if your work substantially worsens the condition.

Example:

Suppose you have mild arthritis in your knee, and your job requires heavy lifting, causing your arthritis to worsen significantly. In that case, workers’ compensation may cover it—especially if your doctor confirms that your work activities accelerated the degeneration.
If you had a prior back injury, but a new work-related accident caused severe pain, herniation, or loss of mobility, the work injury may be considered the prevailing factor.

Common Challenges When Filing a Claim for a Pre-Existing Condition

Filing a workers’ compensation claim involving a pre-existing condition can be more complicated than a straightforward injury claim. Here are some of the biggest challenges workers face:

1. Employers and Insurers Denying the Claim

Insurance companies may argue that your job did not cause your injury but was instead a natural progression of your pre-existing condition. They might claim:

Your condition would have worsened regardless of your work activities.
You had symptoms before your work injury.
The injury was due to normal aging or wear and tear.

2. Difficulty Proving the “Prevailing Factor”

Because pre-existing conditions already exist, it can be challenging to prove that a new injury substantially worsened the condition rather than progressing naturally.

3. Medical Evidence and Independent Medical Exams (IMEs)

Workers with pre-existing conditions often face requests for Independent Medical Exams (IMEs). These are doctor evaluations requested by the insurance company—and the doctor may try to minimize the role of work-related activities in worsening your condition.

4. Pre-existing conditions and Maximum Medical Improvement (MMI)

If a worker is deemed to have reached Maximum Medical Improvement (MMI) before their new work injury, insurers may argue that additional medical treatment is unnecessary.

How to Strengthen Your Workers’ Comp Claim When You Have a Pre-Existing Condition

Since insurance companies will likely challenge your claim, you must build strong evidence to prove that your work activities aggravated your condition.

1. Seek Medical Treatment Immediately

Prompt medical care is critical. A doctor’s note documenting how your job worsened your condition can significantly strengthen your case.

2. Inform Your Doctor About Your Work Duties

Make sure your physician understands how your job tasks contributed to your condition. Their medical opinion can help establish that your work injury was the prevailing factor.

3. Gather Medical Records

Having past and present medical records can help differentiate between your prior condition and the new, worsened injury. This can be used to show that your job significantly accelerated the damage.

4. Consult a Missouri Workers’ Compensation Attorney

Insurance companies are more likely to deny claims involving pre-existing conditions. An experienced workers’ compensation attorney can present medical evidence, negotiate with insurers, and appeal claim denials if necessary.

5. Be Careful with Independent Medical Exams (IMEs)

If an insurer sends you to an IME, be prepared—these doctors often work for the insurance company. Your attorney can help counter biased opinions from an IME doctor.

Workers’ Compensation and the Second Injury Fund (SIF) in Missouri

Missouri has a Second Injury Fund (SIF), which is designed to provide benefits to workers with pre-existing disabilities or injuries. If you already have a disability and a new work-related injury makes you even more disabled, the SIF may provide additional compensation.

The Second Injury Fund is governed by RSMo 287.220 and is particularly important for workers with pre-existing conditions before their job injury.

Need Help with a Workers’ Compensation Claim?

If your pre-existing condition has worsened due to work and you’re struggling with a denied claim, contact the Law Office of James M. Hoffmann today. We have over 30 years of experience fighting for injured Missouri workers and securing the maximum compensation.