Navigating Workers’ Compensation Claims Involving Preexisting Conditions

From Second Injury Fund documentation to return-to-work planning, our latest article breaks down how Louisiana employers can handle complex workers’ compensation claims the right way.

In today’s workforce, many employees live with chronic or preexisting medical conditions. When workplace injuries occur, determining whether these conditions are work-related can be complex. For Louisiana employers, understanding how to properly report, document, and investigate these claims is critical to protecting both employees and your organization.

The Second Injury Fund

Under Louisiana Workers’ Compensation laws, employers must provide coverage for employees who suffer injuries or illness arising out of and in the course of employment.

The key benefits covered by workers' compensation here include:

• Paying for medical expenses for work-related injuries or diseases.
• Providing wage replacement and rehabilitation benefits to assist in the worker’s return to employment.
• Limiting an employee’s sole remedy to workers’ compensation rather than a tort claim.

Louisiana’s Second Injury Fund (SIF) was designed to encourage employers to hire or retain workers with preexisting medical conditions by reimbursing a portion of workers’ compensation costs when a subsequent work injury combines with a known condition.

For employers, this means understanding not only the basics of coverage and compliance but also how to investigate claims when employees may have preexisting or unrelated health conditions.

Employer Best Practices for Managing Workers’ Compensation Claims

For employees with known medical conditions like asthma, diabetes, back problems, seizures, vertigo, or arthritis, the employer’s risk of a claim may be higher, but the Second Injury Fund encourages employers to hire individuals regardless of a prior diagnosis by reimbursement of some of the costs incurred from a claim.

Regardless of an employee’s conditions, here are best practices you should adhere to with any injury reported on the job:

• Report Promptly: Timely reporting ensures that claims are investigated efficiently and helps avoid delays in benefits or disputes.
• Investigate Thoroughly: Gather all details—where, when, and how the injury occurred—and whether preexisting health conditions may have played a role.
• Collaborate with Claims Consultants: Provide copies of completed Second Injury Fund questionnaires to your LHA Trust Funds claims consultant for accurate and timely processing.
• Promote Early Return to Work: Modified or light-duty work can reduce overall costs and improve employee recovery outcomes.

Keep in mind, the pursuit of a Second Injury Fund requires a medically documented history of the condition and employer knowledge.

Importance of Second Injury Fund Questionnaires

Employers should prioritize obtaining Second Injury Fund (SIF) questionnaires from employees at the time of hire and annually thereafter.

These forms serve several critical purposes:

• Document Employer Knowledge: The Second Injury Fund requires proof that the employer was aware of the employee’s preexisting condition before the injury occurred.
• Facilitate Accurate Claims Handling: Annual updates ensure that any new or evolving medical conditions are documented, reducing disputes over compensability.
• Encourage Inclusive Hiring: The SIF program reimburses employers for part of the claim costs, removing barriers to hiring individuals with prior medical conditions.
• Compliance and Risk Management: Maintaining a consistent process for collecting and storing these forms demonstrates proactive compliance and strengthens the employer’s position during claim investigations.

Considerations for Employees with Known Medical Conditions

Workers’ compensation claims involving employees with medical conditions are a real and manageable risk. Thankfully, the workers' compensation system not only provides coverage for accidents but also work-related diseases or aggravations. It’s critical that employers report claims timely with any relevant information, though.

For employees with known medical conditions, employers face additional challenges in balancing safety, compliance, and accommodation.

Here are some best practices to reduce risk and promote fair treatment:

• Job duty match and accommodation: If an employee has a medical condition and is assigned or regularly performs duties that could exacerbate the condition, like heavy lifting or prolonged standing, the employer should evaluate whether the duty poses undue risk and whether modifications or accommodations are appropriate, subject to ADA or other disability laws that are separate and apart from workers’ compensation.
• Pre-employment medical examinations: Some employers use baseline medical screenings and evaluations to document preexisting conditions. Baseline exams should comply with the Americans with Disabilities Act (ADA) and should never be used to exclude qualified candidates. Documenting the baseline can help clarify which portion of a claim is preexisting versus aggravated by work duties.

Preexisting Conditions & Workers’ Compensation in Action

A common claim scenario involves an employee who suffers a syncopal episode and falls. An employee can be in the course of their duties and suffer dizziness, lightheadedness, or fainting and fall, resulting in injuries. Our claims consultants will assist you in gathering the facts of the accident in order to determine what claims would be considered compensable under workers’ compensation.

The cause of the episode, as determined by medical evaluations in comparison to the employee’s activities at the time of the injury, is an important fact to collect. What was the employee doing at the time of the episode? Were they working in the heat or sitting at their desk? Did they suffer a cardiac event and fall, suffering not only cardiac conditions but also a head laceration?

If so, it may be determined that the cardiac-related care is not compensable, but the wound injury is covered by workers' compensation.

Need Help Navigating Complex Claims?

Ensure that you understand the claims process with LHA Trust Funds. Our experienced claims consultants and risk experts can help you evaluate compensability, manage Second Injury Fund documentation, and create a return-to-work strategy that protects your team and your organization.