What happens when the Injured Worker has a Preexisting Condition?
Case Managers are advocates for the ‘whole person’ – both their medical & psychosocial needs – AND they are ethically obligated to follow the laws and statues of employment legislation. Between workers, employers, providers and insurance companies confusion over which injuries will be considered compensable or preexisting may arise.
EXAMPLE
We recently had a NS case involving a truck roll-over accident. Injuries related to the accident were spleen, kidney, orthopedic injuries, and possible post traumatic syndrome. The IW also had preexisting degenerative arthritis, hypertension and an undetermined status hernia. Due to a limited number of providers available for work injuries in this region, the CM located qualified Doctors and obtained approval for tests so the adjuster & employer could render a decision regarding compensability. The CM educated the IW about the employer and adjuster determining compensability for the hernia. While the employer’s policy excluded any diagnoses of psychotherapy, a provider’s recommended request could be submitted to the plan administrator by the adjuster for consideration. Due to the IW not having other medical insurance, he was concerned some of his medical issues would not be covered by his plan. The CM was instrumental in obtaining medical documentation and DOT physical exam paperwork showing no signs of previous hernias. These facts provided the adjuster and employer with the information needed to determine the hernia was compensable, and also allowed the IW to be referred to a county facility to address the psychosocial issues.
Within 6 months, all parties can see the path to a RTW resolution. The adjuster and employer understood the complexities and worked as a team with the CM to resolve the main injuries in question.
May 2010
Author: Maxine Russell, BSN, RN, CCM
Editor: D.Perry