Effective Claim Handling for PTSD Claims

Trends in workers’ compensation statutes allow for an employee to claim benefits for a diagnosis of Post-Traumatic Stress Disorder (PTSD). It is crucial to handle these claims with care, compassion, and a sense of urgency to defend them properly. The goal of every claim team should be to accept those claims with merit and pay all benefits the employee is entitled to, subject to defenses. Now is the time to review and defend these claims to reach better results and reduce program costs.

What is PTSD?

It is required to understand what PTSD is when being an effective claim handler. Failure to understand its origins, issues concerning compensability, and proper management will result in excessive costs.

Given the complexity of PTSD, it is often left to statute to define when it is compensable and what requirements must be met. There are also questions of statutory presumptions often in place for police officers, firefighters, and emergency medical personnel. Never forget that these presumptions are rebuttable.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is typically the starting point for any PTSD diagnosis. This generally requires the employee to show the following:

• Exposure to actual or threatened death, serious injury, or sexual violence;

• Presence of intrusion symptoms associated with the traumatic event(s);

• Persistent avoidance of stimuli associated with the traumatic event(s);

• Negative alterations in cognitions and mood associated with the traumatic event(s);

• Marked alterations in arousal and reactivity associated with the traumatic event(s);

• Duration of the disturbances for more than one (1) month;

• Disturbances that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; and

• Disturbances that are not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

More and more states that allow for PTSD claims to be compensable require the diagnosis to be made by a licensed psychologist and/or psychiatrist.

Areas of Investigation for PTSD Claims

PTSD claims, even if they are admitted, require extensive and complete investigations. This is a condition that typically will not manifest until some time after the occurrence of the work injury. Timely follow-up and reporting on the employer’s part can assist in the investigation.

The basic level of claim investigation includes:

• Recorded statement of the employee;

• Interview and statements of injury witnesses and co-workers;

• Request and obtain a complete set of medical records. This must include requesting all records related to counseling, mental health care, and substance abuse medical care and treatment.

Obtaining information on the employee’s socio-economic, family history, and education is also essential. Additional areas of background investigation should include:

• ISO Claims search;

• Unemployment and proper workers’ compensation records;

• History regarding other litigation, including instances where the employee was a witness;

• Police reports;

• Court records;

• Credit history and bankruptcy research;

• Child support obligations; and

• Internet/social media research.

It may also include the use of surveillance of the employee if they remain off work.

Use of Multiple Independent Medical Examinations

Defending claims regarding PTSD often requires the use of multiple independent medical examinations. These examinations must address physical trauma and mental health-related issues. Having two or more examinations presents several challenges for which the claim team and defense interests should prepare. These include:

• Timing of the examinations and ensuring all information has been received under permissible discovery;

• Anticipating issues related to objections to discovery requests and the need for pre-hearing limitation and motion practice; and

• Proper timing of surveillance on the injured employee.

Be sensitive to the underlying conditions of the employee – use the velvet glove and not the iron fist. The employee might often need to explain embarrassing situations during a recorded statement or deposition. Work with defense counsel on how to best address these situations if the employee. This is especially required if an attorney does not represent the employee.\

Conclusions

Claims of PTSD can present several challenges for the claim management team and other interested stakeholders. When these claims arise, understanding the legal requirements of establishing the condition as a compensable work injury is crucial. Other steps must include a proactive investigation that goes above and beyond most claims and is conducted compassionately. It also requires multiple independent medical examinations that must be timed correctly. Now is the time to prepare and ensure the claim team is ready to deal with PTSD claims effectively.

 

Michael Stack, CEO of Amaxx LLC, is an expert workers’ compensation cost containment systems and provides education, training, and consulting to help employers reduce their workers’ compensation costs by 20% to 50%. He is co-author of the #1 selling comprehensive training guide “Your Ultimate Guide to Mastering Workers’ Comp Costs: Reduce Costs 20% to 50%.” Stack is the creator of Injury Management Results (IMR) software and founder of Amaxx Workers’ Comp Training Center. WC Mastery Training teaching injury management best practices such as return to work, communication, claims best practices, medical management, and working with vendors. IMR software simplifies the implementation of these best practices for employer and ties results to a Critical Metrics Dashboard.

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.