Why Insurance Adjusters Dig for Pre-Existing Conditions

Corey R. PollardWorkers' compensation & disability attorney · Former insurance defense · Best Lawyers in America®

Back in my early career, I sat on the other side of the negotiation table. I represented insurance defense firms. I learned exactly how Third-Party Administrators (TPAs) like Sedgwick and Gallagher Bassett operate when a nurse, a construction worker, or a first responder files a claim. They treat the Workers’ Compensation framework as a cold system. Their primary goal is cost containment, and one of their favorite weapons is your own medical history.

You suffer a devastating back injury while moving a patient or lifting heavy equipment on a job site. You file your Workers’ Compensation claim expecting the system to support you. The insurance adjuster immediately requests your complete medical history. They are not looking for ways to help you heal. They are digging for a single doctor’s note from five years ago that mentions lower back pain or a minor strain.

Once they find that isolated note, the TPA strategy kicks into high gear. The adjuster denies your claim. They argue that your current catastrophic injury is just an old problem acting up. They want you to believe that because you had a prior ache, you have no right to medical care, lost wages, or future stability now.

How We Anticipate the Defense Playbook

I anticipate this exact tactic in every single case we take at Corey Pollard Law. We never wait for the denial letter to start building your defense. We assume the insurance company will try to blame your past for your present crisis. To defeat them, we go on the offensive with your medical providers immediately.

Under Virginia law, you have the right to receive benefits if a workplace accident aggravates, accelerates, or flares up a pre-existing condition. The burden of proof falls on you to establish that the new incident worsened your state. We work directly with your treating physicians to document this distinction. We ask them to provide specific, legally binding opinions that separate your old minor ache from your new, life-altering injury.

By securing this medical evidence early, we remove the adjuster’s ability to manipulate your records. We force the insurance company to confront the reality of the workplace accident. When they realize we have bulletproof medical documentation showing a clear aggravation of a prior condition, their generic defense strategies fall apart.

Shifting the Leverage in High-Stakes Claims

Securing over $100 million in recoveries for injured workers taught me that proactive litigation destroys template insurance defenses. We do not accept the initial denial as the final word. We litigate to force insurers to cover the full medical reality of your accident, from your initial emergency room visit all the way to Maximum Medical Improvement (MMI).

Insurance companies rely on unrepresented workers giving up when they receive a denial letter citing a pre-existing condition. They count on the intimidation factor. My background in insurance defense allows me to see their moves before they make them. We use the tactics they developed to protect their bottom line and flip those strategies to maximize your Permanent Partial Disability (PPD) benefits and secure your family’s future.

Do not let an insurance adjuster use your medical history to deny you the care and compensation you deserve. You can take control of your claim by securing representation that knows the defense playbook inside and out. Bring your claim letters and medical records to our Richmond office, and we will map out a litigation strategy that forces the insurance company to treat your case with the gravity it demands.