Compensability of Idiopathic Conditions Under the North Carolina Workers’ Compensation Act

A challenging area of defense of workers’ compensation claims in North Carolina is that of pre-existing or idiopathic conditions.  The North Carolina Court of Appeals has recognized and adopted the two definitions of “idiopathic” found in Merriam-Webster’s Collegiate Dictionary:

1. “Arising spontaneously or from an obscure or unknown cause;”
2. “Peculiar to the individual.”

In North Carolina, idiopathic conditions are those which arise “spontaneously” from the mental or physical condition of the particular employee.  Examples of idiopathic conditions include unknown physical infirmities (such as a leg “giving way”), as well as conditions including, but not limited to, epilepsy/seizures, heart disease/conditions, and diabetes.

Compensability of Injury Related to Idiopathic Condition

How is compensability analyzed for employees who have pre-existing or idiopathic conditions?  When the employee’s idiopathic condition is the only or sole cause of the injury, the injury does NOT arise out of the employment, and as a result, is not compensable.  But, the injury DOES arise out of the employment, and is generally compensable, if the idiopathic condition combines with “risks attributable to the employment” to cause the injury.

It is important to note there is no requirement that the “risk attributable to the employment” be a risk greater than that experienced by the general public.  Simply put, if the employment “aggravated, accelerated, or combined with the [employee’s preexisting] disease or infirmity to produce” the injury, then the injury does arise out of the employment, and as a result, is compensable.

Analyzing these Claims

Generally speaking, when you find yourself investigating a claim involving an idiopathic condition for compensability, consider the following analysis:

1. Did the injury occur by accident- was their an interruption of the employee’s normal work routine?

*If no, generally not compensable.

2. If yes, did the injury by accident occur at work/on the employer’s premises during the work day?

*If no, generally not compensable.

3. If yes, was the cause of the accident a risk attributable to the employment?

*If no, generally not compensable.

4. What about if the cause of the accident is unknown?

*Generally compensable.

5. What about if the cause of the accident is solely the result of the employee’s idiopathic condition?

*Generally not compensable.

6. What about if the cause of the accident is a combination of the employee’s idiopathic condition and a risk attributable to the employment?

*Generally compensable.

7. What about if the cause of the accident is solely the result of the employee’s idiopathic condition, BUT, the employment places the employee in a position of increased risk of dangerous effects of the fall, such as on a height, near machinery or sharp corners, or in a moving vehicle?

*Generally compensable.

It is important to note that the compensability of the claim turns on the specific facts of the claim and must be analyzed on a case by case basis.  If you have any questions, you can contact me at jjones@cshlaw.com or 919-863-8846.