4-1-1 on Comp Defenses: Major Contributing Cause vs. Exacerbation of Pre-Existing Condition and Return to Baseline

Bruce Burk

Sarasota, FL (WorkersCompensation.com) – We hear a lot about the defense of major contributing cause in workers’ compensation. However, there is another defense that is a cousin of major contributing cause that is sometimes confused with it. That is the defense that the claimant had an exacerbation of a pre-existing condition and a return to baseline. This article with discuss both concepts and list some tips for using both.

Major Contributing Cause

Major contributing cause — or major cause as it is sometimes referred to — is defined by a cause that exceeds 50% of all other causes. It is similar to the concept of the preponderance of evidence in circuit civil court. Major contributing cause has to be demonstrated by objective medical findings. This means that the industrial accident must be more than 50% of the reason that the claimant needs medical treatment.

Major contributing cause is considered to be treatment-specific, meaning it can be raised to individual prescriptions for treatment, rather than to causes of specific conditions. When doctors give opinions on major contributing cause, it is their prerogative to look at all other possible causes to the condition and isolate the causality of the condition to the industrial accident or to something else.

The opinions that the doctor gives must be within a reasonable degree of medical certainty. A major contributing cause analysis must take any prior accidents and any subsequent accidents into account. Even though an industrial accident was initially the major contributing cause of the need for treatment, in theory a subsequent accident could derail the causal chain and be a superseding intervening cause that alters the percentage of casualty attributed to the industrial accident below 50%.

Major contributing cause also has to take into account the failure to mitigate damages or non-compliance with medical treatment. If a patient has an industrial accident but fails to seek medical care or does not do what their doctors tell them to do, then the major contributing cause could easily change from the industrial accident to the claimant’s omission in seeking appropriate medical care.

Exacerbation of Pre-Existing Condition and Return to Baseline

An exacerbation of a pre-existing condition occurs when a claimant has a prior condition that was once asymptomatic that becomes active again as the result of some type of trauma or event. This is in contrast to an aggregation, where a prior condition is made worse by a new trauma or event. This type of theory is different to major contributing cause because it is tied to conditions, whereas major contributing cause deals more with individual treatments.

An exacerbation means that a claimant’s prior diagnosis becomes active again due to a flare-up and now requires treatment, even if the diagnosis was not being treated.

This can occur, for example, in a low back injury. A claimant can have degenerative low back conditions or osteoporosis and then be involved in an industrial accident, where the degenerative condition is exacerbated and treatment is necessary. In this case, the cause of why the claimant needs treatment is both personal and work-related. But, in theory, the major contributing cause is personal because the majority of the degradation done to the claimant’s low back happened slowly over time.

These claims are like lines on a graph. The condition spikes due to some event, and then symptoms dissipate back down after some medical treatment. In these instances, the best course for the employer/carrier is to authorize a primary care physician to treat the claimant for a period of time until the condition is back to its pre-exacerbation status. At that time, the claimant will have returned to baseline.

When the claimant returns to baseline, the claimant should also be at maximum medical improvement and the need for any treatment will be personal or pre-existing. This type of defense also needs to be supported by medical testimony within a reasonable degree of medical certainty.

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