May 2019 Spark Knowledge

Accident at Work? How to Tell the Difference Between a Work-Related Injury and a Pre-Existing Medical Condition

Alan Daigrepont, CWCP

Senior Claims Consultant

The general public is under the assumption that “if something happens at work, it falls under workers’ comp.” This is incorrect. Simply because an employee has an accident while at work doesn’t always mean the injury and treatment are compensable.

Statute La R.S. 23:1021(1) defines an “accident” as “an unexpected or unforeseen actual, identifiable, precipitous event happening suddenly or violently, with or without human fault, and directly producing, at the time, objective findings of an injury which is more than simply a gradual deterioration or progressive degeneration.”

Although most incidents that occur while on an employer’s premises are considered to be within the course and scope of one’s employment, we must separate what is and what is not part of the reported occurrence.

As an example, consider an employee attending a staff meeting on an ordinary day. He exits the room and his knee gives way, causing him to stumble. His coworkers catch him before he hits the ground and he regains his footing. Is the injury to his knee an accepted claim? No, it is not.

Why not? The employee in our example was known to have multiple issues with the knee that collapsed on him. He confirmed that this incident resulted in no injuries other than the need for treatment of the knee. He did not fall and did not strike any other part of his body in the incident. Treatment was isolated to his knee. Time missed from work was also associated only with the treatment he received.

The claim was denied on the basis of “No Accident” and case law upholds this decision. The “gradual deterioration or progressive degeneration” of the knee removes it from the definition above. The employee’s own confirmation that he did not strike the knee on the ground and suffered no other injuries during the incident removes the knee injury from becoming a covered workers’ compensation claim.

As workers’ compensation Claims Consultants, we must evaluate the entire picture based on the question, “Were there any resulting injuries from this incident?” If the injured worker had struck the ground with his knee or incurred other injuries as a result of the knee giving way, this claim would be different. The actual act of the employee’s knee making contact with the floor is considered an “accident.” Likewise, had he struck his elbow as a result of the knee buckling, the injury only to the elbow would be covered.

Similar situations include when an employee has a syncope episode and falls, suffering resulting injuries. The event of the episode itself is not considered compensable. Only those injuries suffered in the resulting fall are covered.

Claims Consultants often work with public assumptions of what workers’ comp claims entail. We must look deeply into each scenario as well as the past medical history of each claimant to assess whether an “accident” actually occurred.

If you have any questions related to this newsletter, please contact:

Kathy Terry
Vice President of Business Development
Lindsay Minzey
Business Development Specialist