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New York court nixes employer's pre-existing condition argument

One of the aspects of the Affordable Care Act lauded by consumer advocates was the directive regarding pre-existing conditions. For decades, health insurance companies had been denying coverage for individuals who had conditions like asthma or cancer when their policy went into effect. We will cover everything but this, insurers said, even if a new therapy could save your life.

In Workers' Compensation cases, a pre-existing condition may still affect an injured worker's benefits. For example, say an on-the-job injury causes an old injury to flare up or worsens an existing problem. The insurance company may determine how much of the current problem is attributable to the old injury and how much is attributable to the new. Compensation would be adjusted accordingly.

This is called "apportionment." If the old injury were assigned 60 percent and the new injury 40 percent in the current claim, workers' comp would pay just 40 percent of the benefit.

A New York appellate court has decided that, for one man, at least, apportionment is not appropriate. His story, however, may sound familiar.

The worker has had neck and back issues for the past 15 years. This claim related to an October 2010 back injury, caused by a fall at work. Before that, the worker had multiple surgeries and follow-up treatment for a neck condition. The workers' comp judge ruled that the 2010 injury was compensable.

His employer, however, appealed, requesting that the benefit be reduced by apportionment. The previous condition was not work-related, the company argued, and, so, not eligible for benefits.

The appellate court denied the request for apportionment. Yes, there was a pre-existing condition, and it was not work-related. And, yes, the claimant had work restrictions to accommodate that condition.

However, the neck condition had not affected the worker's ability to work full-time or to perform his tasks when this accident occurred.

It is important to note that the court's decision will not affect all claimants with pre-existing conditions. Nevertheless, the decision is a win for injured workers: A pre-existing condition does not automatically reduce benefits.

Source: Business Insurance, "Comp benefits still on the table despite worker's pre-existing condition," Bill Kenealy, June 24, 2015

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  • American Association for Justice
  • NYCOSH-New York Committee for occupational Safety & Health
  • Queens County Bar Association
  • Society of New York Workers' Compensation Bar Association, Inc | 1945
  • National Organization of social security claimants Representatives

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