Are Idiopathic Injuries Covered by Workers’ Compensation?

by | Published on Jan 20, 2016 | Workers Compensation

Idiopathic injuries are injuries that happen without any clear cause or some unknown cause. They can stem from a personal health condition a worker may or may not be aware of such as diabetic episodes, heart attacks, seizures, strokes and blackouts. For workers’ compensation to cover idiopathic injuries, the injury or condition must arise out of and in the course of employment. So what does this mean? If an injury/condition has to arise out of one’s employment, there must be a connecting link between one’s specific duties at work and one’s health problem. For example, a worker working in a high-stress environment may experience a heart attack, and it can be proved that the heart attack was caused by the uncontrollable stress at work. Another requisite is that the injury or health condition occurred while the worker was on the job, meaning he/she was on the clock and not taking a break or commuting.

Idiopathic injuries or health conditions are hard to prove often because there may not be one cause to which they can be pinned down. The claimant has to prove that his/her condition occurred during work and arose from work. A workers’ compensation lawyer undertaking such a case would first review the medical information with the support of a medical record review company to determine if there is a convincing case. Attorneys advise their clients to proceed with the case only if there is substantial evidence that can be put to use.

Consider the case of an employee sitting at his desk and begins to feel back pain. This claim is very likely to be denied as having nothing whatsoever to do with his work. The claimant would lose not because the injury is idiopathic but because it doesn’t arise from his job. If a claimant suffers an injury regardless of where he was located and there is no inherent risk posed by any condition of his job, then a causal connection cannot be established between the employment and the injury. In simple words, the consideration would be whether the claimant’s injury could have occurred anywhere, but just happened to occur when he was at work. In idiopathic injury cases, insurers and employers may be able to limit liability at hearings by presenting medical evidence that shows that the claimant’s injury may have occurred whether he was/wasn’t at work. This would involve stringent medical record review and doctor depositions in idiopathic claims.

The following facts are important for a workers’ compensation practitioner:

  • When there is no connection at all really between the injury/condition and the employment, there is no valid idiopathic defense case.
  • The burden of proof is on the claimant who will have to prove that the injury arose from work.
  • The burden of proof shifts to the employer if the employee mentions some work event. In this case, the employer will have to prove that the medical condition was pre-existing and was responsible for the work event.
  • Every employee may have prior conditions when joining work. If the employee’s duties aggravated or worsened a prior condition, the employer may be liable to pay workers’ compensation benefits.
  • If the employer can demonstrate that the nature of the worker’s duties did not really cause the injury, but that the preexisting condition was already there and was the cause of the pain or injury, the employer may not be held liable.

In the United States, a few states cover most idiopathic injuries in workers’ compensation, most states cover those that meet tight restrictions, and some states deny workers’ compensation for any idiopathic injury.

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