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.
Firefighters
Workers’ comp presumptions apply to many different conditions and injuries. The most common include but are not limited to:
Heart disease
Because the laws are constantly evolving, workers’ comp presumptions are subject to change. Recent trends have seen states introduce or enact presumptions related to mental injury, including Post-Traumatic Stress Disorder (PTSD), as well as certain cancers and various emerging conditions.
At least 25 jurisdictions tracked by the National Council on Compensation Insurance (NCCI) recognize “mental-mental” injuries – those that arise without a physical injury – as being compensable.1 In 2024, NCCI monitored 64 bills related to workers’ compensation and mental injuries, including 51 relating specifically to PTSD.2 Other mental injuries may include anything from stress to anxiety or depression.
In Healthesystems’ 2024 Workers’ Comp Industry Insights Survey Report, 52% of respondents ranked mental health conditions and coverage as their top industry concern. When probed in follow-up interviews, most respondents’ concerns were linked to presumptions.3
As of this writing, South Carolina is the latest state to introduce a mental injury presumption for first responders. The bill (H 3261), introduced in December 2024, would allow first responders to file claims for stress or mental injury unaccompanied by a physical injury, assuming they encounter a significant traumatic experience or situation in the line of duty.4
While mental injury presumptions have traditionally applied primarily to first responders, in December 2024 New York passed two breakthrough bills (SB 6635/AB 5745) that grant all workers the right to file a claim for mental injuries premised upon extraordinary work-related stress incurred at work.5 However, in February 2025, New York passed a new bill (SB 755) amending the law to apply the provisions only to first responders. The law also redefines qualifying conditions, covering only mental injuries resulting from a “work-related emergency” rather than general workplace stress.6
In 2024, several other states introduced bills expanding coverage for mental injuries beyond first responders to occupations such as crime scene investigators and dispatchers7:
As mentioned, PTSD is an area of mental injury that more states are including in workers’ comp presumptions. First responders are typically eligible for these presumptions because they are much more likely to experience PTSD than the general population.8
In 2024, several states enacted legislation creating a presumption of compensability for PTSD in certain first responders9:
In addition to expanding to new states, PTSD coverage is expanding to new occupation types. For instance:
A Washington bill (SB 5454), which went into effect in January 2024, added presumptive coverage for PTSD as an occupational disease for direct care nurses.10
A Vermont bill (H 55), enacted in June 2024, expanded PTSD coverage to certain state employees.11
One of the most significant bills (SB 913), enacted in Connecticut and taking effect in January 2024, extended coverage for PTSD from first responders and frontline workers to all employees if they experience a qualifying traumatic event on the job.12
And in January 2025, several more states introduced bills expanding PTSD presumptions to new occupations:
Oregon’s bill (SB 606) would amend the PTSD presumption for first responders and dispatchers to include certain healthcare workers.13
Virginia’s bill (HB 1951) would amend the PTSD presumption for law enforcement officers and firefighters to include dispatchers.14
Washington’s bill (HB 1070) would expand PTSD coverage to correctional officers.15
Cancer is a leading cause of death for firefighters.16 In fact, all 50 states have presumption laws relating to firefighters and cancer.17 Some states use a broad definition of cancer in their presumptions, while others list specific types of cancer.
In 2024, at least six states introduced bills relating to cancer presumptions. Of these, several states enacted legislation expanding presumptions to different types of cancer18:
Hawaii’s bill (HB 1889) added presumptions for breast cancer and cancer of the female reproductive organs for firefighters.19
Maryland’s bill (SB 476) added presumptions for thyroid, colon, or ovarian cancer for first responders.20
West Virginia’s bill (HB 4537) added presumptions for bladder cancer, mesothelioma, and testicular cancer for firefighters.21
And in January 2025, several more states introduced cancer presumption bills:
Florida’s bill (HB 87) would add leukemia to the list of 21 types of cancers already accepted under its presumption law for firefighters.22
Hawaii’s bill (SB 828) would expand workers’ comp coverage for firefighters to additional cancers, including adenocarcinoma or mesothelioma of the respiratory system, cancer of the buccal cavity, colon, pharynx, and thyroid, and malignant melanoma.23
Mississippi’s bills (SB 2404/HB 1531) would update cancer presumptions for firefighters to extend benefits to retired firefighters. Current legislation only applies to active firefighters.24
Nebraska’s bill (LB 400) would establish a rebuttable presumption of cancer as an occupational disease for firefighters. The bill lists carcinogens associated with over 20 different types of cancer, including bladder, brain, breast, and lung cancer.25
We are also seeing legislation expanding cancer presumptions to occupations beyond firefighters. For example, in October 2023 California passed a bill (SB 391) requiring workers’ comp programs to cover skin cancer for first responders, lifeguards, and certain peace officers of the Department of Fish and Wildlife and the Department of Parks and Recreation.26
And in January 2025, Connecticut introduced a bill (SB 1029) that would expand the state’s cancer presumption to apply not just to first responders but to “other workers” impacted by similar conditions.27 Though the bill does not specify which types of workers would qualify, it can be presumed that “similar conditions” would imply occupational exposure to harmful carcinogens or other substances.
In the past year, we’ve seen proposed and enacted legislation that continues to expand to conditions beyond what have historically been associated with workers’ comp presumptions. Highlights include:
In June 2024, Louisiana enacted a bill (HB 326) that classified hearing loss as an occupational disease for state police.28
In November 2024, Texas pre-filed a bill (SB 454) proposing an infertility presumption for firefighters and EMTs.29
In January 2025, Connecticut introduced a bill (SB 462) that would recognize substance use disorder as an occupational illness for employees affected by repetitive strain injuries in the workplace.30
Also in January, Virginia introduced a bill (SB 1112) that would recognize injuries or diseases caused by repetitive trauma as occupational illnesses.31
In February, New York introduced a bill (AB 4457) that would make compensable the death of an injured worker who was determined to have died from an opioid overdose.32
Because of the unique nature of presumption laws and the fact that they apply to specific populations, treatment for impacted injured workers may be atypical for workers’ compensation. For instance, prescription drug therapies for these workers may not be included in standard drug formularies.
This could mean increased friction for the injured worker at the pharmacy counter, as the necessary medications may trigger prior authorizations that can delay care. This may also cause difficulty for claims professionals, who will be required to spend time reviewing and approving the prescription.
For payers with these occupations in their covered populations, partnering with their Pharmacy Benefit Manager (PBM) on a customized strategic approach is important. Population-specific formularies can be leveraged to support access to timely treatment and improve both the injured worker and the claims team experience. For claims staff, these formularies will help to remove unnecessary prior authorizations on medications that are clinically appropriate and cost-effective for the treatment of presumptive conditions.
As mentioned, workers’ comp presumptions generally only apply to certain worker populations such as first responders. But what about employees in other occupational groups who end up with the same exact workplace exposure and resulting diagnoses?
Critics of workers’ comp presumptions believe that creating laws covering some populations and not others can lead to inequity in claims management and access to care. For instance, a factory worker and a firefighter may both have a cancer diagnosis following exposure to carcinogens. But due to presumption laws, the firefighter has easy access to workers’ comp benefits, while the factory worker has to fight to prove work exposure resulted in cancer.
This controversy is exacerbated by the fact that, for some presumptive conditions, there is conflicting data to support that certain work populations have a greater likelihood of experiencing them. Using cancer as an example: In a multi-year study of 30,000 career firefighters, the National Institute for Occupational Safety and Health found that firefighters had a modest increase in cancer diagnoses (9%) and cancer-related deaths (14%) as compared to the number of cancers expected using U.S. population rates.33
However, some studies refute these findings. One example is a later study by the Journal of Occupational and Environmental Medicine that looked at 14,748 cases of lung cancer. Results showed that there was no increased lung cancer risk among firefighters overall or by specific cell type.34 Furthermore, a position paper by the United Kingdom-based Industrial Injuries Advisory Council states that there is consistent evidence that mortality and cancer incidence in firefighters for all cancers considered together do not show any excess risk compared to the general population.35
The data may be, in part, what is shaping some states’ approach to making some of the more recent presumption bills occupation-agnostic.
