The Effects of Underestimating Degenerative Conditions in Workers’ Compensation Claims

Degenerative conditions, especially those associated with comorbidities like hypertension, chronic pain, or diabetes, can present serious roadblocks in the path to recovery for an injured worker. Yet, their impact is often undervalued due to the common nature of some conditions. Not only can they greatly skew the outcome of a claim, but they can also completely alter the course of what may have started as a treatable injury.

“Degenerative conditions, such as arthritis or degenerative disc disease, can be aggravated by repetitive motions, heavy lifting, or other physical demands of the job, leading to increased pain, reduced mobility, and potential disability,” said Andrea Young, Large Casualty Workers’ Compensation Claims Manager at Safety National. “Employers should encourage early reporting, conduct thorough assessments, implement safety measures and consider modified duties. If an employer ignores a workers’ compensation claim involving a degenerative condition, they can face significant consequences such as legal penalties and fines, civil liability, criminal charges, increased workers’ compensation premiums, stop-work orders, difficulty proving the prevailing factor, and an increased risk of denied claims.”

Underestimating degenerative conditions can be particularly problematic, causing:

Inaccurate Risk Assessment

Understanding an injured worker’s overall health profile is critical to providing an accurate risk assessment. Misjudging an injury’s severity, such as degenerative disc disease, which may become a chronic, progressive issue, can limit the ability of insurers, employers, and claims professionals to assess medical needs, adequately reserve, and forecast claim trajectories.

Delays in Treatment and Recovery

Comorbid conditions can complicate treatment plans, slow healing, and increase the likelihood of complications or re-injury. When these issues are not identified early in the process, an injured worker may receive inadequate or incomplete care. Misaligned care can lead to delayed recovery, prolonged or permanent disability, and frustration for both the worker and the employer.

Underestimated Costs

Comorbidities can cause claims to be significantly more expensive. Recent data shows medical payments and indemnity benefits can more than double when even one comorbid condition is present. Failing to capture this data accurately in the early stages of a claim can lead to budgeting miscalculations and unexpected costs.

Challenges in Return-to-Work Planning

Effective return-to-work programs require a full understanding of the injured worker’s capabilities and limitations. Degenerative and chronic conditions, especially those affecting mobility, endurance, or mental health, may affect an employee’s ability to perform certain tasks. When these conditions go unrecognized, employers may develop return-to-work plans that are not appropriately tailored, increasing the risk of setbacks.

Misaligned Incentives and Systemic Gaps

Most medical providers follow reimbursement rules that prioritize compensable and reimbursable diagnoses in documentation. As such, degenerative conditions often fall outside of the compensable scope of a workers’ compensation claim, which leads to selective reporting. Additionally, when the degenerative condition is not recognized in the claim, it can cause fragmented care, where important health factors are acknowledged clinically but not reflected in billing data or claims documentation, leaving gaps in communication and care coordination.

Lack of Insight for Prevention and Policy Making

At a systemic level, underestimating degenerative conditions means missing opportunities for trend analysis, predictive modeling, and policy development. Without accurate data, it is difficult for industry stakeholders to craft targeted interventions, improve outcomes, or address the needs of an aging workforce.