Morgan’s Tip of the Week-Idiopathic analysis and responsibility
Greetings, idiopathic claims remain some of the most difficult claims to navigate. Lately I have had a few questions on what and when we are responsible in an idiopathic claim in FL. The 1st DCA did issue a good case back in February, Silberberg, and my Tip on that is below. To summarize where we are now, it’s a two-part analysis:
- Was the accident caused by a pre-existing condition?
- This is the E/C’s burden to prove either through prior records, the authorized treater or a subsequent IME. If you can’t prove it was caused by a pre-ex condition, you are stuck with the claim.
- In Silberberg, his leg fell asleep and he then fell when he got out of his chair and fractured his leg. The E/C’s IME diagnosed him with venous insufficiency, which caused his leg to fall asleep, which caused the fall. So, check, there was a pre-ex condition that caused the fall. BUT….
- Even if there is a pre-ex condition that caused the accident, did the workplace create any increased hazard?
- In Silberberg, the DCA looked at the chair, the floor, that he was not rushed or an emergency, nor did he have to sit for a prolonged time. They determined there was no increased hazard. Not compensable.
- If there is a pre-ex condition that caused the fall, and the workplace posed no increased hazard, the claim can be denied in its entirety.
In these situations, without an increased hazard, we don’t have to pay for the leg injury or any part of the claim, the entire claim is denied as it does not “arise out of employment”.
However, let’s say there was an increased hazard, an emergency fire drill that he had to leap up out of his chair for example. In that case, we would NOT have to treat the pre-ex venous insufficiency condition, but we would have to arguably treat the broken leg.
We would only have to treat the pre-ex condition if the accident aggravated the condition, and the accident is and remains the major contributing cause of the need for the treatment. Possibly, if the pre-ex condition is a hinderance to recovery, we may have to treat it as well to be able to treat the compensable injuries (for example getting diabetes under control).
Hope this helps. There is a reason we have a CEU entitled “The # 1 question in WC, is it idiopathic?”.
Morgan Indek | Managing Partner