To listen to a discussion of this topic via podcast, head on over to The Comp Pod with Andy and Ivy.
Under most state workers’ compensation laws, “ordinary diseases of life” – those to which the general public is equally exposed – are not compensable. In these cases, the burden of proof is on the employee to prove that a disease or injury claim is related to their job.
However, in the last decade the industry has seen a wave of presumption laws, which shift that burden of proof from the employee to the employer. While these have traditionally focused on specific occupations with unique work conditions, such as first responders, we have recently seen proposed and enacted legislation that expands presumptions to new occupations and conditions.
These presumptions impact workers’ comp populations differently. For instance, we have seen greater impacts on state funds and municipalities that cover specific populations with unique needs, such as law enforcement and firefighters. For payers covering these impacted populations, a customized approach is important to promote access to appropriate treatment in a timely manner. Formulary management can be a valuable tool to support efficient and effective care for injured workers while streamlining the prior authorization process for the claims management team.
As more legislation is introduced, presumption laws will continue to change and expand. Let’s look at the latest presumptions in workers’ comp and the workers who are impacted.
Presumption Criteria
To be eligible for presumptions, employees must meet certain criteria, which vary by state. These criteria include:
- Minimum service requirements
- Time limitations related to the number of years following retirement or termination
- Age restrictions
- Submittal to health evaluations (pre-employment or ongoing)
Who Is Eligible for Workers’ Comp Presumptions?
While recent legislation in some states aims to expand presumptions beyond select occupations, historically they have largely applied to:
- Firefighters
- Law enforcement (police officers, corrections officers)
- Healthcare workers(doctors, nurses, EMTs)
- State and federal employees
- Various other occupations
