No two stress statements are the same. An employee may suffer a serious injury, such as an amputation, and not seek treatment for anxiety related to the incident, even though it would appear to be a reasonable request. However, another employee may experience a minor back strain at work without a disability and claim psychological distress, which could raise questions. Two employees may witness the same violent incident at work. The first employee continues with no residual psychological symptoms, while the other suffers from severe post-traumatic stress disorder (PTSD).

Regardless of the circumstances, workers’ compensation claims for stress can be a pain point for employers. In this blog, we will:

• Detail the different types of psychological claims in workers’ compensation (WC)
• Describe how to recognize when psychic claims have merit
• Review benefits for injured workers with actual claims
• Explain how employers and claims professionals can fight suspicious claims
• Suggest preventive measures for employers to reduce the filing of claims

Categories of psychiatric claims

State jurisdiction matters when it comes to psychiatric claims – more so than any other type of WC claim. Only about eight states offer WC coverage for mental-only claims without physical injury. Most US states cover them in limited situations, such as health care workers, first responders or victims of violent incidents. California excludes claims for cumulative mental trauma if the employee has not worked for his employer for at least six months or if the reported stress was due to a good faith action by the staff. Other states require only that the alleged stress be caused primarily by work factors. The National Council on Compensation Insurance (NCCI) has noted that more states that previously denied psychiatric claims are beginning to accept them.

Data from the California Workers’ Compensation Insurance Rating Bureau (WCIRB) shows that incidents of workplace violence are on the rise, with a large portion of these claims involving mental diagnoses such as PTSD.

Some industries have seen more mental-only claim filings, such as those filed by restaurant workers. Conformable Insurance businessin 2021, heavy workloads, unusually high demands and pressure caused claims of mental stress to rise 71% over pre-COVID levels. This is largely due to the fact that food service companies were not prepared to deal with the shortage of staff left behind by the pandemic.

Aside from purely mental claims, the most common type of psychiatric claim is one related to a physical injury. These tend to be accepted more often, especially if the physical injury is serious. Depending on the jurisdiction, the benefits provided to injured workers for these types of claims may be more limited compared to benefits for physical injury. For example, an employee with anxiety may be entitled to medical treatment with a therapist and prescriptions, but not entitled to disability.

Differentiating between valid and questionable psychiatric claims

Before choosing to fight a psychiatric claim, consider its validity. Does the state where the employee works provide coverage for psychiatric injuries? Is the employee a long-term, highly motivated, responsible individual whose workload has increased substantially in the absence of adequate resources for support? Did the employee witness a violent attack? If an employee has suffered a serious or complex physical injury and is unable to work, some degree of anxiety or depression is normal. Remember that all individuals differ in how they deal with stress. It is best not to compare one injured worker’s mental response to injury or stress with that of another. Instead, ask what mental reaction might be considered reasonable for most individuals.

Physical injuries are tangible obstacles that individuals face. Whether it’s a sprained ankle, a strained back, or a broken bone from an accident, the focus is primarily on the physical aspect of recovery. However, what often goes unnoticed is the profound impact these injuries can have on an individual’s mental health.

The consequences of physical injuries extend beyond the pain and discomfort associated with the injury itself. Sudden loss of mobility and independence, disruption of daily routine and inability to participate in usual activities can lead to feelings of frustration, sadness and isolation.

In addition, the fear of re-injuring yourself or uncertainty about the degree of recovery can create significant anxiety. This may be especially true for workers whose identity and livelihoods are closely tied to their physical abilities.

Undoubtedly, some psychiatric claims are suspect and should be challenged. It’s often easy to recognize the red flags. These include but are not limited to:

• The employee files a grievance after being terminated or following disciplinary action, such as a performance improvement plan.
• The employee claims stress symptoms due to a minor physical injury.
• The employee has a history of previous claims, particularly those alleging stress.
• The employee is employed on a short-term basis.

How to fight against a questionable claim of stress

Claims adjusters may use jurisdictional defenses as a first line of defense. Obviously, if mental health claims are not covered by the state in question, there is no need to investigate further. The claim can be rejected outright.

Past medical records and employee depositions can be helpful in determining the extent of workplace psychiatric symptoms versus personal non-industrial stressful circumstances. This documentation can help medical examiners and medico-legal evaluators form an opinion about industrial causation if work is a substantial contributing factor to the employee’s psychiatric symptoms and the duration or level of disability due to the employee.

Sub-rosa video surveillance is not limited to physical injury claims and can be effective in psychiatric claims as well. For example, if an employee has alleged work-related depression that causes an inability to function, a deposition combined with a sub-rosa video could help disprove the claim. Imagine an employee who testifies in a deposition that she can’t go out or have a romantic relationship because of her depressive symptoms. The employer tips the adjuster with details of the employee’s upcoming wedding, scheduled immediately after filing. An investigator successfully films the employee during her wedding ceremony and reception, complete with table dancing. Showing this type of film with the contradicting transcript of the doctor’s deposition will probably annoy them because they gave the employee a sympathetic ear – this may cause the doctor to change his mind about the employee’s right to benefits.

Personnel records are needed to support a defense in the event of litigation that often follows claim denial. This is especially relevant in states like California, which allow the claim to be denied when the stress is due to bona fide staff actions or when the employee has worked for the employer for less than six months.

Reducing stress claims and claim severity

Incorporating mental health into the workers’ compensation claims process requires a multifaceted approach that involves collaboration between employers, claims adjusters, medical providers, and mental health professionals. Employers play a key role in creating a supportive work environment that prioritizes employee well-being.

Employers should not immediately dismiss or refute an employee’s stress report, even if such a report does not seem valid.

Remember, everyone experiences situations differently. Listening, validating and providing internal resources can go a long way and reduce the chances of the employee making a WC stress claim.

Such resources may include referrals to health care providers, EAPs, wellness applications, or other forms of confidential counseling. These additional supports are also useful alongside a valid WC stress claim as they can reduce the severity of the claim, including time lost from work. Improved mental health is known to lead to improved injury outcomes.

Insurers and health care providers also have a responsibility to ensure that mental health services are available and easily accessible to injured workers. This may involve using nurse case managers, coordinating care plans that address both physical and mental health needs, and facilitating timely referrals to mental health specialists.

Balancing Vigilance and Care in Workers’ Compensation Claims

It is essential to recognize and challenge dubious psychiatric claims, but mental health is also a key part of other WC injuries and requires close and proactive attention. Recognizing and treating real workplace mental stress and the psychological impact of physical injuries is critical to effective holistic recovery and positive claim outcomes.