What is a Major Cause in a Workers’ Compensation Case in Massachusetts?
Workers who suffer from pre-existing conditions must prove that their work-related injury is a “major cause” of their disability to be eligible for workers’ compensation benefits in Massachusetts. Typically, a pre-existing condition will not prohibit an injured employee from receiving workers’ comp benefits. However, the question of what constitutes a “major cause” could be a determining factor in whether those benefits are awarded.
One of the primary reasons an insurer gives to deny a workers’ compensation claim is that the disability the injured employee is suffering from resulted from their pre-existing condition rather than the work-related injury. As a matter of course, you are not entitled to benefits solely for a pre-existing condition. Because determining whether the work-related injury was a “major cause” is a fact-depended argument, you should have our Wakefield crane accident lawyer and Boston workers’ compensation lawyers advocating on your behalf.
The Law Office of John J. Sheehan has handled complicated and challenging workers’ compensation cases. While the law was intended to provide an expedited way to obtain benefits, insurance companies often have other ideas, especially if an injured worker suffers from a pre-existing condition.
Major Disability Causes in Massachusetts Workers’ Comp Cases
When you file a workers’ compensation claim in Massachusetts, you will have to undergo several examinations and medical assessments to determine the degree of your disability. The insurance provider will attempt to ascertain if your injury will result in a partial, total but temporary, or a permanent disability. If you have a pre-existing condition, it will be factored into this assessment. Furthermore, the pre-existing condition could be used by your employer or their insurance provider to allege that your current injury has nothing to do with your work-related injury. In a workers’ compensation claim, this is commonly known as the “combination injury defense.”
Should the insurance company raise this defense, the burden shifts to the injured worker to demonstrate that the work-related accident was a significant or major cause of their current disability. The workplace injury does not have to be the primary cause of the injury – just a major cause.
Therefore, if your workplace injury exacerbated a pre-existing condition, you could still qualify for workers’ comp benefits. The existence of an older condition will often open a door for an insurer to try and deny your claim or limit your benefits.
Goodwin v. National Grid Defined Major Cause in Massachusetts
The question of how to define a “major cause” was answered in a 2012 case.
The Facts of the Case
In 2012, a Massachusetts court helped define what was meant by a “major cause.” William Goodwin was a 55-year-old man who spent most of his working life as a pipefitter for the defendant. His general duties required strenuous physical labor. In December of 2008, when attempting to fix a leak in an overhead pipe, Goodwin felt a pop in his neck and a shooting pain down his right arm.
The Workers’ Compensation Claim
After reporting the incident and going to the doctor, Goodwin was diagnosed with multiple disc degeneration caused by degenerative disc disease. According to the examining doctor, the work-related injury aggravated the pre-existing condition. However, by further explanation, the doctor indicated that the pre-existing condition was responsible for 60% of his current condition and the work injury contributed 40% to his disability. Relying on this determination, the workers’ comp insurance carrier argued that the work-related injury was not a major cause of Goodwin’s disability.
Hearing Before an Administrative Law Judge
When the claim was heard before an administrative law judge, the judge found that the doctor applied an improper legal standard in his conclusion. Furthermore, aside from the improper legal standard, the judge determined that 40% was sufficient enough to qualify for workers’ compensation benefits.
The company’s insurance provider appealed this decision. The argument was that the pre-existing condition was the primary cause of Goodwin’s disability. However, the court found in favor of Goodwin. The court held that the administrative law judge was within his rights to find that the doctor’s definition of “major cause” was incorrect.
The Aftermath of Goodwin v. National Grid
So, what should our Massachusetts workers’ compensation attorneys take from this decision? at its core, the decision appears to hold that workers who aggravate a pre-existing condition are eligible for benefits even if the work-related injury is not the dominant cause of the disability.
Nonetheless, the above case illustrates a very common fact pattern that workers’ comp attorneys face on a daily basis representing injured workers. For example, a middle-aged construction worker might have injured his back lifting something heavy on the job. Prior to this accident, he could have suffered several minor back injuries over the years working construction, but he always returned to work. However, this present lifting injury is bad, and the employee, in all likelihood, will not be able to return to heavy construction work. After the incident is reported, the insurance company sends the employee for an insurance medical examination (IME). The IME report says that the employee has arthritis and degenerative disc disease in the lumbar spine. Furthermore, the report concludes that the employee may have suffered a lumbar sprain which has since been resolved and that the ongoing problems and disability are not related to any work injury. Given this conclusion, the insurance company terminates the employee’s workers’ compensation benefits and refuses to approve any future medical treatment.
The above fact pattern is typical and is the basis for the legal defenses addressed in Goodwin’s case. Without an experienced Cambridge workers’ compensation lawyer, the injured employee might never obtain the benefits they deserve.
Evidence Workplace Injury is a Major Cause
Now that our Malden workers’ compensation lawyers have a working definition of “major cause,” the next step is determining what evidence is necessary to demonstrate a work-related injury contributed enough to a pre-existing condition to qualify for benefits. Some types of evidence our lawyers will use are listed below.
Emergency Room Records/Accident Report
An incident report and emergency room records are important to establish that an employee was injured on the job. If the injury was serious enough to warrant a trip to the emergency room or an urgent care facility, it will be helpful to refute an insurance company’s claim that the injury was not a major cause of the workers’ disability.
Medical Treatment Records
Medical records are a key component in any workers’ compensation case, especially if the claim is being disputed. If an injured worker has medical records indicating treatment, follow-up care, and rehabilitation, it could provide compelling evidence that the work-related injury was a major cause of their current incapacity.
A Gap in Medical Treatment
In most cases, a gap in medical treatment in a personal injury case is a red flag. However, in a workers’ comp case involving a pre-existing condition, a gap in medical treatment could be important evidence that the pre-existing condition was not causing a debilitating problem until the work-related injury aggravated it.
Contact Our Experienced Massachusetts Workers’ Comp Lawyers if You Have a Pre-Existing Condition
If you have any questions concerning Massachusetts workers’ compensation benefits, even if you are receiving benefits, you should contact Attorney John Sheehan to discuss your case. Call (617) 925-6407 today.