Demystifying presumptions in workers’ compensation

January 3, 2024

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By Max Koonce, Chief Claims Officer

Workers’ compensation systems in the U.S. date back to the early 1900s – the first comprehensive law protecting injured workers was passed in Wisconsin in 1911. By mid-century, all states had introduced legislation that began the framework for today’s modern system regulating wage benefits and medical care for occupational injury and disease. 

Though changes have been made in the century since its inception due to cultural, generational and technological changes in the workplace, the system has stayed true to its original construct: to be an equitable balance between the interest of the employee and the employer.

Disease has historically not been widely compensable without evidence-based demonstrations or legislative definitions. But for certain job roles and for certain diseases — depending on the state’s presumptions laws — employees may be eligible for benefits without the need to prove causation, bypassing the normal claims process. 

Presumption in workers’ compensation is a small area of workers’ compensation law that has significant implications on how legislators, workers and insurers move forward. This blog will give an overview of this topic.

What is a presumption? 

A presumption, simply stated, is an inference as to the existence of one fact from the proof of another. Within the context of workers’ compensation, presumption statutes state that certain diseases are more likely to occur with workers in certain employment exposures given the specific physical and emotional demands of their work, but causation as arising directly from work may be difficult to prove.

The claimant must first establish that the presumption applies, and that the condition arose or developed out of and during their term of employment or, in certain jurisdictions, within a certain time frame after retirement. Under a presumption law, upon proving these facts, the disease is presumed to be compensable. Employees can then move forward through the claims process and receive benefits.

What determines eligibility for presumptions?

State governments set workers’ compensation statutes and determine eligibility for presumptive benefits. Every state has its own unique workers’ compensation landscape and by consequence its own unique set of presumption laws. 

Presumptions in workers’ compensation apply primarily to certain public entity employees, such as first responders — police officers, emergency medical technicians and firefighters – and apply for certain conditions or diseases these employees may encounter as a risk during their term of employment.

Some examples include:

  • For firefighters, 26 states have enacted workers’ compensation statutes that cover one or more types of cancer, while 21 states have statutes that cover respiratory disease; 
  • For police officers, 11 states have enacted workers’ compensation statutes that cover heart or vascular diseases, and 7 states have statutes that cover mental health and PTSD; 
  • For EMTs, 12 states have enacted workers’ compensation statues that cover blood and infectious diseases. 

Who in the workers’ compensation system do presumptions affect?

While the specifics of eligibility by profession, by disease/injury, and from state to state, presumptions impact several groups of people:

Injured workers – As the claimants, injured workers benefit from these laws. Presumptions redistribute the balance in favor of the injured employee, provided they meet the criteria for eligibility. 

Employers and insurers – Presumptions increase coverage areas for employers and workers’ compensation insurers if they are required to provide benefits. Presumption statutes typically cover injury/disease that are a part of everyday public health issues with disputable connections to the work environment. Therefore, a risk that employers can not address solely from a safety prevention standpoint and a risk that is challenging for insurers to allocate for because of the tenuous connection to employment exposure. 

Medical professionals – Workers’ compensation claims must be supported by medical evidence. Presumptions may influence how healthcare providers diagnose and report injuries and diseases.

Legal professionals – Attorneys are crucial in interpreting their state’s workers’ compensation regulations and applying presumption law, serving as an advocate for their clients’ interests.

What causes challenges or controversies in presumptions?

At its most basic concept, presumption statutes alter the burden of proof. As previously noted, for coverage under workers’ compensation, when an employee is diagnosed with a disease or injury, the employee must prove that the disease or injury arose out of and in the course of their employment. With presumptions, half of the required equation is met by statute since presumption statutes assume a causal connection between the injury/disease and the employment. 

Presumption statutes are typically applicable to only certain employee classifications. Compensability presumptions typically apply to specific employment genres: police officers; firefighters; and first responders. These distinctions create different classifications of injured workers that have a lower threshold to prove compensability than the general employee. 

Presumption statutes also potentially broaden workers’ compensation coverage beyond what are employment related risks for which employers have no ability to control or prevent. Such broadening could generate the perception that the focus of workers’ compensation is moving towards “socialization of risks” and less on the distinctions of work-related risk and its attendant focus on a safe and productive work environment.

In recent years, legislators and politicians have increased activity in using and expanding presumptions – this is especially pressing with COVID-19 in the rearview, which accelerated and evolved expectations regarding how openly infectious diseases are considered. Every year, there is more legislative activity around presumptions not just for first responders and public service providers but expanded even broader in the healthcare industry. 

Presumptions are a timely and hot topic as state legislative sessions resume in the new year. Once again, states will be evaluating changes and expansions to their workers’ compensation laws, which will have ripple effects that impact everyone in the ecosystem. 

Learn more > Read the workers’ compensation flyer here.

Tags: benefits, Casualty, Casualty claims, claim, Employee, Employees, employer, Helping people, injury, Legislation, People, presumption, workers' comp, Workers' compensation, workplace