What Happens When an Insurance Company Says Your Injury Was a Pre-Existing Condition?

It’s aggravating enough having to go through insurance claims to receive compensation for an injury. However, when an insurance company tries to deny the claim due to unrelated pre-existing conditions, the frustration can lead many to give up the fight. The insurance company’s sudden claim that your injury is just an old condition flaring up involves one of the most common tactics used to reduce or deny personal injury claims. This defense can feel personal and confusing, especially when you know your pain started after the crash. Understanding why insurers use this strategy, and how personal injury lawyers in Massachusetts and Rhode Island can fight it, puts you in a stronger position to recover the compensation you deserve.

Why Insurance Companies Raise the Pre-Existing Condition Defense

Insurance adjusters are trained to find any reason why the amount they have to pay should be reduced. A pre-existing condition provides such a reason. If the adjuster can cite a prior back injury, a past knee surgery, or an earlier car accident, the company can claim that the pain you are experiencing now is due to that history rather than the recent event. As a result, the financial responsibility is moved from the at-fault driver’s insurance policy back to you.

The reason this method is effective is that medical records for accident claims frequently contain a record of previous aches, strains, or long-term problems. Nearly all adults aged 30 or over have a medical file containing at least one past injury or complaint. When insurers look at these records, they choose to focus on the facts that back up their version of events and overlook any evidence showing that your condition had suddenly got much worse following the accident.

The Legal Difference Between a Pre-Existing Condition and an Aggravation

Rhode Island and Massachusetts law recognizes an important legal principle called the eggshell plaintiff rule. This rule holds that an at-fault party takes the injured person as they find them. If you had a prior back condition that was manageable before the crash, and the accident made it significantly worse, the person who caused the accident is responsible for that worsening, even though you were more vulnerable than someone with a completely healthy back.

However, having a pre-existing condition does not automatically exclude you from making a claim. What is important is to show how the accident worsened your condition and in what specific ways it did so. Courts and insurers divide by which condition was present before and did not change as a result of the accident, whether the condition was aggravated or made worse by the accident, and if the injury is entirely new and there is no previous history. The amount of compensation you receive will depend on proving which of these cases applies to your situation.

Common Pre-Existing Conditions Insurers Target

Some injuries are more likely to lead to this defense than others since they affect parts of the body that are susceptible to degenerative changes over time. If you know which conditions are most likely to come under examination, you will be able to anticipate the argument and have your evidence ready from the start. The most common are:

• Degenerative disc disease or prior back and neck injuries, since spinal wear is common with age
• Previous knee, shoulder, or joint injuries from sports, work, or earlier accidents
• Arthritis or other chronic joint conditions that show up on imaging regardless of a new injury
• Prior whiplash or soft tissue injuries from an earlier car accident
• Mental health conditions such as anxiety or depression that existed before a traumatic accident

How Insurance Companies Build Their Case Against You

Adjusters never make guesses when they carry out a thorough investigation into your medical history via various methods. They ask for your medical records stretching back for many years, at times as far as 10 or more years earlier, to look for any reference to similar pain or treatment. They often use independent medical examiners-doctors who are chosen and paid by the insurance company-whose usual finding is that your present symptoms are due to a previous condition rather than the more recent accident. They also look at your social media accounts for personal injury history and search for old posts that talk about pain, injuries, or physical limitations prior to the crash.

Steps to Protect Your Claim

By taking the correct actions following an accident, your position will be strengthened should the defense of a pre-existing condition be raised. The steps involved are designed to establish a clear medical and factual record which distinguishes your original condition from the new injury caused by the accident.

• Seek medical treatment immediately after the accident, even if your pain seems minor at first, since gaps in treatment give insurers room to argue your injury developed later or unrelated to the crash
• Tell every doctor about your complete medical history, including any prior conditions, so your records show honesty and consistency rather than gaps an insurer can exploit
• Describe your specific symptoms in detail, noting what changed after the accident, such as new pain locations, increased severity, or reduced mobility compared to before
• Keep a daily journal documenting your pain levels, activities you can no longer do, and how your condition compares to your baseline before the accident
• Gather statements from family, friends, or coworkers who can describe your physical condition and activity level before and after the crash

All of these actions establish a factual timeline which supports your account of what happened and opposes the insurer’s effort to blur the distinction between old and new injuries.

The Role of Medical Evidence in Overcoming This Defense

The difference between a claim being rejected and one being settled involves having strong medical documentation. The doctors who are treating you can give what is known as a causation opinion, which is a professional medical statement outlining how the accident caused or made your condition worse. By comparing images taken before and after the accident-for example, X-rays or MRIs-objective changes are often found that support your claim. A doctor’s note indicating that your condition was stable and well controlled before the accident but then became much worse after it has considerable influence with insurance adjusters and, if needed, with a jury.

Medical experts are also able to explain the process of aggravation using terms that non-medical people can understand. For instance, a specialist in the spine can describe how the forces caused by a car accident can speed up damage to a disc which was already wearing out but was not giving rise to daily pain prior to the crash.

Rhode Island and Massachusetts Handle Comparative Fault Differently

In Rhode Island and Massachusetts, it is possible for people who have been injured to claim compensation even if a pre-existing condition has played a part in their injury, but the rules on comparative negligence are different. Rhode Island has pure comparative negligence, which means that you can get damages even if you are found to be largely at fault for the accident, the amount of compensation being reduced by the proportion of fault you are found to have. Massachusetts uses a modified comparative negligence with a 50% rule, which means that damages can only be claimed if you are found to be less than 51% at fault.

The rules concern liability for the accident, not the argument about the pre-existing condition, although insurers often attempt to combine the two issues in order to confuse the claimants. Experienced personal injury lawyers in Rhode Island and Massachusetts are able to clearly distinguish between these concepts when negotiating your settlement or when presenting your case.

Get Help From Our Trusted Rhode Island and Massachusetts Injury Attorneys

A skilled personal injury attorney will know how to get the appropriate medical opinions, secure complete records which give the full account, and set out a clear account that distinguishes your previous health condition from the new injury caused by the accident. This careful preparation usually results in a fair settlement instead of the claim being denied or reduced.

You should be aware that when an insurance company says your injury is merely a pre-existing condition, it’s usually employing a standard tactic and that doesn’t mean the matter is finally settled. The personal injury lawyers at d’Oliveira & Associates have for many years been assisting injured individuals in both Rhode Island and Massachusetts in resisting unjust insurance claims and in obtaining the compensation they are entitled to.

Sources

• https://www.rid.uscourts.gov/juryinstructions/jccv_negligence_eggshell_skull_doctrine