I usually tell clients with accepted workers’ compensation claims to assume they continue to have medical coverage into the future for conditions caused by the work injury or work exposure, but I will also caution them that the insurer is free in the future to question whether it must pay for a particular medical service. A recent case shows the difficulties that an injured worker may face in the future. Mr. Fowler had sustained an L4-5 disc herniation in an 1992 work injury. He underwent low back surgery and later received a permanent partial disability award.
Years later, Mr. Fowler underwent surgery for a “recurrent” L4-5 disc herniation. The insurer denied the recurrent disc herniation. Mr. Fowler argued it was the same condition as the accepted condition. The Workers’ Compensation Board held that the recurrent disc herniation was not the same condition as the initial disc herniation. And, because the recurrent disc herniation was not directly caused by the original work injury, but instead was a “consequential condition”, then Mr. Fowler was required to prove the work injury was the major cause of the recurrent disc herniation and not merely a material cause. The board also found that, although the first injury and surgery partially contributed, the major cause of the recurrent disc herniation was a degenerative process and passage of time. The board therefore ruled against Mr. Fowler. He did not get coverage from his work injury claim for the surgery to treat the recurrent disc herniation. John C. Fowler, 61 Van Natta 329 (February 12, 2009). (Our office did not handle this case; it was a case published by the Workers’ Compensation Board.)
Cases such as this show the need to carefully obtain persuasive medical opinions from the doctors involved in order to prove the necessary relationship between the injury and need for medical services.
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