Understand The Work Comp Heart Attack Presumption

The grand bargain of the workers’ compensation system requires employees who allege work injuries or conditions to prove compensability of their claim. This includes the initial threshold question that it “arose out of” and occurred within the “course of” their employment activities. While this threshold question applies to all employees equally, there are various presumptions that allow firefighters, police officers and other emergency personal to obtain compensation for heart attacks or other exposures with a lesser degree of evidence. This is known as the “heart attack presumption,” and is something all members of the claims management team should understand. They should also be aware as to how to deal with these cases and rebut the presumption when appropriate.

Origins of the Heart Attack Presumption

Employees that work in emergency situations deal with a constant flow of stressful situations during the course of every workday. This includes rushing to various emergencies, working prolonged and abnormal hours and being subject to constant peril. The result was a recognition in multiple jurisdictions that these professionals should receive additional protections that while rebuttable, allow them to peruse legitimate claims without having to prove issues of causation to the extent that other employees are required.

Application of the Presumption

It is important to note that the occurrence of a heart attack by a firefighter, police officer or other emergency responders does not automatically trigger compensability. In order for the presumption to be successful, there is typically a requirement of “an absence of contrary or conflicting evidence on the point and the circumstances which form the basis of the presumption must be of sufficient strength from which the only rational inference to be drawn….”[1] In other words:

• The employee must fall into the “protected class” given their employment;

• There must be some medical evidence that demonstrates a connection between the heart attack and the employee’s work activity; and

• The connection must be rational or reasonable.

In all jurisdictions that have such statutory presumptions, the employer/insurer are able to rebut it with evidence to the contrary. Other jurisdictions have imposed pre-employment physical requirements and limited the applicable qualifying conditions.

Rebutting the Heart Attack Presumption

When reviewing any workers’ compensation claims, members of the claims management team have a duty to their insured to investigate fully the allegations made before rendering an opinion on compensability. This includes instances where a qualifying employee suffers a heart attack. In those instances, the ability to rebut the presumption is defined in statute or interpreting case law. Examples of the presumption rebuttal include:

• Proof of causation that a non-work related event took place at the same time as the heart attack and was manifested itself in the alleged condition;

• Contemporaneous medical evidence that demonstrates the existing of a condition, which was not related to the employment and resulted in the heart attack; or

• Evidence that the employee died from a condition other than a heart attack, and the death was not related to one’s employment.

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Practice Tips and Pointers

Any workers’ compensation investigation should be ethical and diligent. In instances of a heart attack, the following additional steps should be taken:

• Obtain a complete medical history and set of medical records for the claimant;

• Obtain complete pharmacy records for the claimant. The use of medications for high blood pressure, cholesterol or other conditions are important to the claims investigation; and

• Schedule an independent medical examination with a board certified cardiologist to determine issues of causation. In instances of death, an autopsy may be necessary.

Conclusions

The existence of a heart attack presumption is part of the grand bargain to ensure fairness in compensation for emergency workers. While this may result in the payment of a claim under a lesser standard of scrutiny, it is important for members of the claim management team to understand how it works and rebut the presumption when evidence suggests non-work related factors were the real result of the condition or death from a heart condition.

[1] Hopson v. Hungerford Coal Co., 187 Va. 299, 305, 46 S.E.2d 392, 395 (1948).

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Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

Contact: [email protected].

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.