Whether mental health claims are compensable under Workers’ Compensation insurance is not a simple answer. It depends on a number of factors including state Workers’ Comp standards and the individual situation. There are two types of mental health claims that an employee can pursue under workers’ compensation: “mental/mental,” in which no physical injury occurred, and “physical/mental” whereby a workplace physical injury has progressed to a mental condition or disability.
Mental/Mental Health Claims
Mental/mental claims are much more complex to establish and have a harder threshold in proving a link between the workplace and the mental condition. In fact, some states don’t allow mental/mental health claims at all while others have specified the elements necessary to establish a Workers’ Compensation mental/mental claim. For example, Maryland, Washington, D.C., Ohio, West Virginia, North Carolina, Georgia, Alabama, Arkansas, Oklahoma, South and North Dakota, Wyoming and Montana don’t allow any types of mental/mental claims. States like New York, Pennsylvania, Indiana, Kentucky, Tennessee, Florida, New Mexico, Arizona, Utah, Nevada, Washington, and others allow mental/mental injuries to be covered only under limited circumstances such as a sudden or unusual incident that can be pinpointed to a specific time date, or just for first responders.
California is among a few states where mental/mental claims may be compensable in accordance with a list of standards that must be met. A worker must be employed by the employer for a minimum of six months. The employee must have a psychiatric condition outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) (stress is not a condition) and must be able to show that the actual circumstances of his or her employment caused the psychiatric condition by at least 51% or more. Personnel actions that an employer takes in good faith, such as criticism of an employer’s work, lack of punctuality or attendance, or decisions about qualifying for a raise or promotion, cannot be claimed as the cause of the condition. In addition, litigation cannot be a reason for the claim nor can job termination unless the employer knew about the employee’s injury or treatment before termination. Oregon, Illinois, and others also have their own requirements for mental/mental claims compensability.
Physical/Mental Health Claims
More common than mental/mental claims are physical/mental claims, in which a mental injury is attached to a physical Workers’ Comp claim. Let’s say, for example, an employee suffers a back injury on the job and becomes depressed as a result of his or her inability to work and significant lifestyle changes. The mental health claim is more likely to be compensable in this situation but it’s important to note that each case must be looked at on its own merit and the facts involved. No two claims are the same.
What is clear is that, when a mental injury is added to the mix, what would have been a straightforward physical injury claim that may have taken a few weeks or months to treat could be prolonged significantly or turn into a total disability.
Claims Investigation and Return to Work
During the claims investigation, it’s important to look into a claimant’s prior medical history including whether a comorbid mental condition exists that may become exacerbated by a workplace-related injury. In doing so, the adjuster can get a better handle on the impact a comorbidity will have on the time it will take, and an employee’s ability, for him or her to recover and get back to work.
At Prescient National, we feel it’s critical to have a light-duty return-to-work program in place to help facilitate the claims process and address injured employees. The sooner individuals return to work, even in a modified-duty situation, the better they will feel about themselves physically and mentally. They aren’t focused on the fact that they are out of work or on the injury itself but instead are being productive and working toward improving their health. A light-duty return-to-work program is also good for employers as it lowers costs, both in Workers’ Compensation indemnity payments and medical expenses.
About Prescient National
Workers’ Compensation specialist Prescient National is all about knowing what’s coming around the corner. Our approach involves foreseeing, planning, and executing perfectly because, through anticipating legal trends, sensing market shifts, and understanding how projected economic cycles impact Workers’ Compensation, we have an informed vision for the future – these are the key drivers we deliver in our products, programs, and risk management strategies. Prescient National offers solutions to employers based on their individual needs, risk-taking appetite, and loss history: guaranteed cost policies, small-, mid-size, and large-deductible policies, retrospective rating policies, excess/self-insurance, and captive options.
