Florida’s workers’ compensation system is built to move quickly. You get hurt on the job, you report it, and the carrier begins paying medical care and, if needed, wage loss. That’s how it should work. Where many claims go off the rails is the pre-existing condition denial. A claims adjuster reads one line in an old medical record, sees the words degenerative disc disease, arthritis, or prior knee injury, and stamps the file “denied.” I’ve sat across from hundreds of injured workers who heard that word and assumed they had no case. That assumption costs people treatment, wages, and leverage. The law in Florida is more nuanced, and a denial tied to a pre-existing condition can often be challenged and reversed when you know how to build the record.
This is the roadmap I use as a workers comp attorney in Florida when a carrier justifies a denial by pointing to pre-accident health issues. It blends the statutes, medical realities, and the practical levers that actually move claims.
What Florida Law Really Says About Pre-Existing Conditions
The workers’ compensation statute does not exclude people with imperfect bodies. Florida recognizes that many adults carry wear and tear, especially in the spine, shoulders, and knees. The key legal tests are major contributing cause, apportionment, and occupational causation.
Major contributing cause, often shortened to MCC, means the work accident must be the primary driver of the need for treatment, more than 50 percent as compared to all other causes combined. That threshold comes from section 440.09(1) of the Florida Statutes. When the carrier says your degenerative disc disease, not the lifting accident, caused your pain, they are really arguing the accident is not the MCC. The judge of compensation claims, if your case goes that far, will look for competent substantial evidence on MCC. That usually means medical opinions stated within a reasonable degree of medical certainty.
Apportionment and aggravation go together. If you had a pre-existing condition that was asymptomatic, then a work accident made it symptomatic, the work accident can be the MCC of care even if the degenerative process still exists in the background. On the other hand, if a doctor credibly testifies that half of the treatment relates to pre-existing degeneration and half to the accident, the judge can apportion benefits, which reduces but does not eliminate what the carrier must pay. In real life, this often shows up with spine cases where MRIs reveal both acute changes and age-consistent bulges.
Causation is medical. Your testimony matters, but to win a dispute about MCC, you need a physician willing to say the work event is the major contributing cause. Carriers know this, so they try to shape the first medical records with language that undermines causation: “chronic,” “longstanding,” “non-radicular,” “no objective findings.” Getting clean, accurate early documentation is a quiet battle that decides many claims before anyone steps into a courtroom.
Where Denials Based on Pre-Existing Conditions Come From
Adjusters do not wake up hunting for denials. They work within claims-handling protocols and metrics. The most common triggers for a pre-existing denial are: late reporting, a gap in treatment after the incident, intake forms that mention prior similar pain, surveillance or social media suggesting the person functioned well post-accident, and radiology reports written in general terms. I have seen more denials launched off a single checkbox than I care to admit. For example, a new-patient packet at the authorized clinic asks, have you ever had back pain? The injured worker checks yes, thinking about stiffness after long drives years ago. That box Workers compensation lawyer near me becomes the headline in the denial letter.
Imaging and old charts cut both ways. An MRI that shows multilevel degeneration, especially in workers over 35, is common. Carriers lean on that. Yet the same MRI often contains findings consistent with an acute injury: an annular tear, bone marrow edema, or a new herniation impinging a nerve root. Old records can help by showing you were symptom-free before the accident, or that you had a prior injury that fully resolved. The single best factual pattern to challenge a pre-existing denial is a clean pre-injury period followed by a specific incident with immediate symptoms documented by an authorized physician.
The First 30 Days Matter More Than Most People Think
Early moves have outsized impact. When a denial is brewing, you want to control what goes into the file and how quickly it goes in. The carrier has a 120-day window to investigate compensability while paying without prejudice, but some deny outright within days if they smell a pre-existing issue. The best practice is to report the injury promptly, be consistent in your description of the mechanism, and avoid minimizing symptoms during the first clinic visit out of pride or fear. I have represented firefighters, electricians, and nurses who were trained to downplay pain. That instinct reads like inconsistency in a record.
If the carrier denies, ask immediately for a written Explanation of Benefits showing the reason code. Pin them to the basis, not for theatre, but so you know whether you’re fighting MCC, notice, or some other technical issue. If the adjuster hints they’ll reconsider after they get pre-injury records, do not wait passively. Offer a targeted release for primary care and relevant specialists 2 to 3 years pre-accident, then track that request. The narrower the release, the less irrelevant history ends up in the file muddying the waters.
How an Experienced Workers Compensation Lawyer Builds the Rebuttal
When the denial rests on pre-existing conditions, the work happens on two tracks: medical opinion and factual clarity. I start with the accident narrative in plain language. A simple, consistent story repeated across forms and depositions carries weight: I was lifting a 60-pound box from floor to waist height, felt a sharp pull in my lower back, and pain shot into my right leg within minutes, worse with bending. Then I compare the first clinic note, any ER records, supervisor reports, and text messages to make sure the timestamps and mechanism match. Small contradictions are fixable with context, but ignoring them lets the denial calcify.
On the medical side, I push for an evaluation with a physician who understands occupational causation. Not every good doctor understands workers’ compensation causation standards. In neck and back cases, I look for objective findings that correlate with the complaints: reduced reflexes, dermatomal numbness, positive straight-leg raise, or Spurling’s test. In shoulder cases, a traumatic labral tear or acute bursitis on ultrasound can be persuasive. The report needs to state plainly that the industrial accident is the major contributing cause of the need for care, and explain why degenerative findings, though present, are not the primary driver of current disability or treatment.
Sometimes that first neutral authorized doctor won’t give a helpful opinion. Florida law allows one-time changes of physician when the carrier has accepted the claim. In denials, we often need an independent medical examiner. These IMEs cost money, but they can flip a case. When I decide whether to spend on an IME, I ask: are there objective signs, is the mechanism credible, and can imaging be read in a way that supports acute aggravation? If two answers are yes, the IME is usually worth it.
The Role of Imaging and How Words on a Radiology Report Can Save or Sink a Case
Radiologists write for other clinicians, not judges. Terms like degenerative, multilevel spondylosis, and desiccation do not rule out a work injury. What matters is whether there is evidence of acute change that plausibly connects to the mechanism. An annular fissure with high-intensity zone on T2 sequences often correlates with recent injury. A focal herniation compressing the traversing S1 root matches sciatica symptoms. In shoulder MRIs, a full-thickness supraspinatus tear in a 42-year-old roofer with no prior symptoms looks different than mild chronic tendinopathy in a 62-year-old office worker.
When the carrier hangs its hat on radiology language, I sometimes obtain a second-read by a musculoskeletal radiologist and ask targeted questions: are any findings consistent with acute trauma, is there edema suggesting recent injury, and do the imaging findings correlate with the reported symptoms? A well-written addendum that ties images to anatomy and function can move an adjuster off a rigid position.
Apportionment: A Real Risk and a Negotiation Lever
Not every win is all-or-nothing. Apportionment can reduce indemnity or medical responsibility when a doctor credibly splits causation. For example, a surgeon might say 70 percent of the need for a lumbar laminectomy stems from the industrial injury and 30 percent from pre-existing stenosis. Practically, this can look like the carrier paying for surgery but later challenging ongoing care beyond a certain point, or trying to reduce impairment benefits. I assess apportionment risk early, because it influences settlement value and strategy. In some cases, embracing a reasonable apportionment position unlocks needed care now while preserving the right to fight about the tail end of treatment later.
Common Pitfalls That Sabotage Good Claims
I see the same avoidable mistakes. Gaps in care invite skepticism. If you wait three weeks after an incident to see a doctor, the carrier will argue something else caused your pain. Inconsistent histories are harmful. Telling the urgent care it was a “twinge,” then later describing a heavy lift with immediate sciatica, gives the defense cross-examination fodder. Posting workouts, lawn projects, or beach trips on social media while saying you can’t bend or lift feeds surveillance narratives, even when the photos don’t reflect how you felt afterward. Finally, aggressive self-treatment can backfire. Chiropractor visits outside the authorized network generate records that the carrier will dismiss and may use to argue you improved without their care.
Depositions, Statements, and How to Tell the Story Without Overreaching
Adjusters and defense attorneys look for certainty when uncertainty would be more honest. If you had low-grade aches before the accident, say so, then explain the difference after the incident, focusing on function. For example, before the accident my back would get stiff after long days, but I never had pain down my leg and I never missed work. After the box lift on April 12, I couldn’t sit more than 10 minutes without burning pain to my right calf. Those details attach credibility to your testimony and match how doctors think.
Avoid diagnosing yourself. You don’t need to say “herniated disc” or “labral tear.” Describe sensations, limits, and timelines. Anchoring your memory with concrete markers helps: it was the Friday before Easter, I reported it to Luis at 2 p.m., he told me to finish the shift and go to Concentra in the morning. If you already had a bad knee and the job required kneeling on metal grates, explain frequency and duration. That kind of context supports aggravation as MCC even in the presence of degeneration.
When to Push for a Surgical Opinion and When to Hold
Surgery recommendations are leverage. A credible orthopedic or neurosurgical opinion that you need an operation turns a theoretical debate about pre-existing degeneration into a concrete medical necessity. Carriers become more cautious denying surgery across the board, especially where acute findings exist. That said, rushing to a surgical recommendation without adequate conservative care can expose you to apportionment or give the defense an argument that the doctor didn’t exhaust other options. In spine cases, I usually want documented failure of physical therapy and injections unless the neurological picture is clear-cut. In shoulder cases, persistent weakness and imaging consistent with full-thickness tears often justify a prompt surgical consult.
Mediation and Settlement Dynamics in Denied Pre-Existing Cases
Denied cases often settle, but the timing matters. If you settle too early, you accept a carrier’s story before you build your own. I prefer to mediate after securing at least one supportive medical opinion on MCC and, ideally, a clear treatment plan. If your IME states that you need a microdiscectomy and attributes it primarily to the accident, the cash value of that recommendation anchors negotiations. On the other hand, if your only support is your testimony and a generalist clinic note, the number will be soft.
Negotiating requires straight math and risk assessment. You weigh the cost of care likely to be approved if you win, the chance of apportionment, wage loss exposure, and litigation costs. In Florida, most injured workers care more about timely medical care and stability than about squeezing every last dollar. A settlement that funds an immediate surgery through health insurance or a lien resolution can make more sense than two years of litigation over MCC. A seasoned workers comp lawyer will walk you through those trade-offs, not just posture for a courtroom victory.
Tactical Use of Petitions, EOB Challenges, and the 120-Day Rule
Florida’s 120-day rule can save a claim. If the carrier begins providing benefits and fails to deny within 120 days after it knew or should have known of material facts, it can be estopped from denying compensability later. This does not cure everything, but it can force acceptance of the accident as compensable even if specific treatments remain disputed. When adjusters drag their feet, I file petitions for benefits early, not to be combative, but to start the clock on mediation and preserve leverage.
When a denial cites pre-existing conditions, I sometimes file a targeted petition for diagnostic testing that connects causation. For example, an EMG to confirm radiculopathy. A normal EMG does not kill a case, but an abnormal one can shut down a degenerative-only argument. If the carrier pays for diagnostics while maintaining a denial, keep an eye on the 120-day timeline. Their payments may trigger acceptance unless they clearly reserve rights.
Real-World Examples that Show What Works
A 38-year-old delivery driver lifted a 70-pound box, felt immediate midline low back pain, and developed right leg numbness within hours. The clinic note called it a lumbar strain, conservative care was ordered, and the carrier denied treatment after an MRI showed multilevel degenerative changes at L4-5 and L5-S1. We obtained a second read noting a right paracentral herniation with annular fissure at L5-S1, correlating with S1 symptoms. The IME, a board-certified neurosurgeon, opined the accident was the major contributing cause. The carrier reversed denial and authorized a microdiscectomy. The driver returned to work eight weeks later.
A 55-year-old custodian with known knee arthritis slipped on a wet stair and felt a pop. The carrier cited arthritis to deny. The authorized orthopedist’s MRI report referenced “tricompartmental osteoarthritis” but also noted a “complex medial meniscus tear with displaced fragment.” The doctor apportioned 60 percent to the work accident, 40 percent to arthritis. We accepted apportionment, obtained arthroscopic surgery authorization, and later negotiated a settlement that accounted for potential future knee replacement exposure.
A 46-year-old nurse with mild intermittent neck stiffness developed constant neck pain and right arm weakness after repositioning a patient. Initial urgent care notes mentioned “chronic neck pain,” a phrase the nurse did not use but landed in the record. The carrier denied. We collected two years of pre-injury records showing only sporadic ibuprofen use, no radicular complaints, and full duty. An IME documented objective C6 weakness and recommended a selective nerve root block, then ACDF if needed. The strong functional contrast between pre- and post-accident states carried the day. The claim was accepted with no apportionment.
What You Can Do Right Now if You’ve Been Denied Over a Pre-Existing Condition
- Get the denial letter and any Explanation of Benefits in writing. Identify the exact reason code and the dates of service denied. Request your initial clinic or ER records and read the mechanism and history sections. If something is wrong or incomplete, ask the provider for an addendum. Identify all pre-injury providers for the same body part in the last two to three years and gather records that show baseline function. Keep a simple journal for the next 14 days tracking pain levels, functional limits, and any activities you cannot perform at home or work. Talk to an experienced workers compensation lawyer who regularly litigates MCC and apportionment disputes in Florida, not just files forms.
Choosing the Right Advocate
Not every workers compensation attorney treats pre-existing denials the same. You want an experienced workers compensation lawyer who will get under the hood quickly, not wait six months to address causation. Ask how often they use IMEs, whether they have relationships with musculoskeletal radiologists, and how they approach apportionment negotiations. Location matters less than readiness to act, but if you search workers compensation lawyer near me or workers comp lawyer near me, prioritize firms that show courtroom outcomes and not just settlement stories. A good workers comp law firm will be direct about the strengths and weaknesses of your file. If someone promises easy money without reviewing records, be cautious.
Look for practical support as well. Will the firm help coordinate short-term disability or FMLA if wage benefits are denied? Do they communicate in plain English? Can they connect you to providers who understand workers comp documentation? The best workers compensation lawyer for your case is the one who marries legal skill with medical literacy and steady communication.
The Medical-Legal Bridge: How to Talk With Your Doctor
Doctors do not like legal fights in the exam room. Respect that, and you will get better notes. Arrive with a concise timeline, describe function not just pain, and ask one key question when appropriate: Doctor, based on your exam and the imaging, is the work accident the major contributing cause of my need for treatment right now? You are not asking the doctor to advocate, only to state an opinion that the law requires. If the doctor hesitates, that is data your attorney needs. It may be time for a second opinion.
Bring a short list of job duties to help your doctor connect findings to function. For a warehouse picker, repeated bending to mid-shin, twisting, and carrying 30 to 50 pounds matter. For a home health aide, patient transfers and awkward postures matter. When the record reflects the physicality of your job, it becomes easier to attribute aggravation to work rather than general aging.
When Litigation Is Worth It
Some denials will not budge without a judge’s order. Litigation takes time, usually months, and adds expense to both sides. It becomes worth it when you have a credible mechanism, early consistent reporting, objective findings, and at least one supportive medical opinion. I file and take depositions of treating doctors and IMEs to lock in MCC opinions. If I believe apportionment will be argued, I address it head-on, asking doctors to explain their percentages and the basis for them. Judges listen closely to reasoned, anatomically grounded testimony and tend to discount conclusory statements.
An underrated benefit of litigation is clarity. Even when cases settle before final hearing, the discovery process forces everyone to commit to positions. That often reveals the weak pivots in a pre-existing denial and opens the door to a practical resolution.
Final Thoughts for Workers and Employers
For injured workers, a pre-existing condition is not a dead end. Florida’s system cares about whether work is the major contributing cause of the treatment you need today. A well-documented aggravation can be compensable, and apportionment can manage the parts that fairly belong to the past. Swift, accurate early records, a focused medical strategy, and steady legal pressure change outcomes.
For employers, training supervisors to document incidents cleanly and refer promptly for care reduces disputes. When your team member gets timely, appropriate treatment, they return faster and litigation risk drops. Partnering with a workers comp law firm that understands both sides of these claims can align incentives rather than inflame them.
If you are staring at a denial that leans on the words degenerative or pre-existing, do not let that be the last word. Align your facts, secure the right medical opinion, and get a workers comp attorney who knows how to turn a paper excuse into a path forward. A denial is a position, not a verdict.