Why was workers’ compensation denied?

Why did the insurance institution stop paying compensation even though I hurt my shoulder in an accident at work? Why does the insurance institution consider my sick leave to be due to wear and tear even though I have not had any problems with my shoulder before the accident at work?

This brochure contains instructions for employees who have had an accident at work, for the occupational safety representatives, occupational safety managers and occupational safety ombudsman who provide advice to injured employees at the workplace, and for the employees’ supervisor(s). Also included in the brochure are brief descriptions of typical cases of injuries in which the compensation payable under the workers’ compensation insurance is disappointing, as well as the reasons for the lack of insurance coverage.

'' Back strain injury

Back strains are common injuries. Based on medical experience, a strained back usually takes a few weeks to heal. If healing takes longer than that, the symptoms are usually caused by a disease that is not related to the strain injury, such as sciatica.

Sciatica refers to a shooting pain starting in the lower back or buttock and radiating down the front or back of the thigh and leg and/or feet, caused by a herniated disc. A common strain injury cannot cause disc herniation to an otherwise healthy disc; however, a strain injury may trigger sciatica symptoms caused by disc degeneration. In such a case, the cause of the symptoms is a degenerative disc disease rather than the movement that caused the strain injury.

The only time that a herniated disc is compensable as an occupational accident is when it is caused by the transfer of energy to the lumbar spine from an outside force, which could occur, for example, when landing on one’s back in a high fall onto a hard surface or object.

'' Knee injuries

The knee joint is formed by the joints between the thigh bone and shinbone and the thigh bone and kneecap. The knee is easily injured by various strains and blunt trauma.  As a load-bearing joint, it is also prone to degenerative diseases. A minor strain or blow to a worn-out knee can cause a difficult spiral of complications, even if the person only experienced minor symptoms or no symptoms at all prior to the injury.

Ligament sprains are the most common type of knee injury and, in most cases, a causal connection clearly exists between the accident and injury. However, knee pain experienced in an already damaged knee may not be caused by an accident.

The meniscus in the knee can be torn in an accident. It can also be torn due to degeneration. A meniscus damaged by a degenerative disease can be torn even without an accident, for example, on the ascent of a squat. Compensation is only paid for a meniscus tear resulting from an accident.

Partial or complete dislocation of the kneecap are also common knee injuries. If the dislocation occurs due to structural reasons without any impact from an external factor, it is not an accident. This can occur, for example, when dancing or on the ascent of a squat.

Chondromalacia, i.e. softening of the cartilage, is a fairly common disease. It is also often the only cause of knee pain found in medical examinations. Chondromalacia is not covered by workers’ compensation insurance.

'' Shoulder injuries

The shoulder joint has the greatest range of movement of any joint in the human body. Shoulder osteoarthritis, also known as degenerative joint disease of the shoulder, and the resulting inflammation are very common problems especially in older age. Studies have shown that more than one in two people aged 50 and over have degenerative changes in the shoulder joint without them causing any symptoms under normal circumstances.

Typical degenerative changes in the shoulder joint include thinning or calcification of the rotator cuff, partial tendon tears, inflammation of the bursa, presence of fluid in the sheath of the long head of the biceps tendon, bone spurs in the acromion of the shoulder, or osteoarthritis in the acromioclavicular joint.

The degeneration of the shoulder joint associated with ageing reduces the resilience of the shoulder joint with regard to accidents.  Therefore, when deciding on compensation for shoulder tendon tears, it is also necessary to assess the significance of disease-related factors in the case concerned. Degenerative changes do not rule out compensation if an accident could have also caused a tear in a previously healthy tendon. An otherwise healthy tendon can be torn if you fall directly on your shoulder when you are, for example, on a ski slope or riding a bicycle. On the other hand, an otherwise healthy tendon usually does not get torn as the result of a normal lifting motion, a slip of the grip or a small yank.

In many cases, complete certainty of degeneration and its effects can only be established through imaging. In general, however, the effect of degeneration has to be assessed on the basis of factors relating to the occurrence of the accident and possibly previous medical records.

'' Torn Achilles tendon

According to medical knowledge, in practice, a healthy Achilles tendon will not tear even if stretched vigorously, as happens when pushing off to a jump, coming down from a jump or lifting a heavy object.  The cause of an Achilles tendon tear is almost always microscopic degenerative changes in the tendon, which are not visible to the naked eye.

While all degenerative changes in the body increase with age, within specific age groups, degeneration of the Achilles tendon can only be found in some people and most people’s tendons remain resilient to Achilles injury. Achilles tendon tear should be considered an asymptomatic disease most often triggered by a sports activity that involves sprinting or pushing off, or by a slip and fall accident. In other words, the main cause of a torn Achilles tendon is degenerative changes in the tendon rather than an accident or overstretching.

'' Abdominal hernias

Hernia refers to a hole or weak spot in the muscle walls that enclose the abdominal cavity, which allows a bit of abdominal contents to push through, creating a lump or bulge. Hernias are generally visible: they will look like a lump or bulge beneath the skin, usually when you are straining. Sometimes hernia may not be immediately visible as a bulge or lump.

When the discovery of a bulge or lump resulting from hernia is related to an occupational accident or work motions, the insured person can easily come to the conclusion that the accident or work motions caused their hernia. The most common hernia claims for compensation are for groin hernia; occasionally claims for compensation are also made for other abdominal hernias. Apart from a few rare exceptions, however, rather than being the actual cause of the hernia, accidents and work motions only cause the hernia symptom – a bulge or lump – to become visible. Hernia itself is a congenital disease, or it may have developed due to a congenital weakness. Sometimes hernia may occur due to surgery or illness. Hernia that occurs due to surgery or illness is not covered under the workers’ compensation insurance even if the visible symptom of hernia – the bulge or lump – was triggered by an occupational accident.

Very rarely is hernia caused by very sharp blows to the abdomen that cause bruising in the abdominal area. Other signs of soft tissue injury may include bleeding into the tissue and tissue contusions requiring surgery.

'' Work-related pain

Provisions on work-related pain are laid down in Chapter 7, section 33 of the Workers’ Compensation Act. Work-related pain refers to non-accidental muscle or tendon pain. It is a mild condition caused by performing a straining work-related motion in the course of the work. A causal connection must exist between the time of onset and mechanism of pain and the straining work-related motion. Compensation for work-related pain is not awarded for bone or cartilage injuries or tissue damage in which the medical causal connection can only be attributed to a sudden and unforeseen event. These include, for example, rotator cuff tears and dislocations of a shoulder or knee. Compensation is also not awarded in cases where the pain develops gradually.

'' Brain injury

Brain injury is sudden damage to the brain caused by a traumatic injury to the head. Brain injuries are diagnosed on the basis of acute symptoms and clinical findings, as well as the findings of a CT or MRI of the head. Based on this information, brain injuries are classified as mild, moderate and severe injuries. Assessment of the severity of brain damage considers the duration and severity of unconsciousness, length of the post-traumatic gap in memory, symptoms and findings detected in the examination of the central nervous system, and results of brain imaging. The symptoms caused by brain injury vary significantly in their severity. Most brain injuries are mild, and those who recover usually become asymptomatic in a few weeks or months.