Mental Trauma Claims

States Ponder PTSD Coverage for First Responders

Four states are weighing bills that address emotional trauma claims from police officers, firefighters and ambulance workers.
By: | May 11, 2015 • 2 min read
Into the fire

First responders who suffer emotional trauma after on-the-job tragedies are the focus of state legislatures in Arizona, Connecticut, Ohio, and South Carolina.

Arizona lawmakers did not vote on a measure that would have created a presumption that post-traumatic stress disorder is occupational for first responders. Instead, the legislators passed and Gov. Doug Ducey signed into law a measure creating a group to study the issue.

H.B. 2438 will allow for a 15-member panel to examine and report on the effects of PTSD on state and local law. The panel must report on its findings by September 2016.


Meanwhile, Connecticut lawmakers continue considering legislation to provide workers’ comp coverage to first responders who suffer mental trauma after witnessing the death or maiming of a person. The measure would expand coverage for police officers, firefighters, and ambulance workers who meet all of the following conditions:

  • Saw a person’s death or maiming or the scene of such an incident within six hours after law enforcement officers secured the scene.
  • The death or maiming was caused by a person rather than a motor vehicle accident or natural cause.
  • A licensed psychiatrist or psychologist determines the worker’s mental or emotional impairment originated from seeing the death or maiming or its immediate aftermath.

The bill would take effect upon passage. It would require “the state, by October 1, 2015, to purchase a workers’ compensation insurance policy to provide coverage for any claims for workers’ compensation benefits for the above injuries,” according to a legislative summary of the bill. “Because the state does not have to purchase the policy until October 2015, municipal employers must cover their own emergency responders’ workers’ compensation claims, as is the practice under current law, between the time the bill is enacted and the state purchases the required policy.”

Opponents have testified that the measure would impose too much of a financial burden on municipalities. Supporters say mental health benefits are just as important as are physical health benefits.

This is the second attempt at such legislation. The first was introduced in 2013 after the Sandy Hook school shootings in December 2012 but was rejected by the state Senate. The latest measure has been referred to a legislative committee.

Legislation before Ohio lawmakers would provide benefits for emergency responders with PTSD. Current law allows coverage only when a related physical injury or forced sexual conduct was present. The head of a legislative panel said he wants to meet with interested parties before the committee votes on the issue.

South Carolina lawmakers are weighing a proposal to also allow first responders to be covered for PTSD. The legislation would provide coverage if the impairment arises from the worker’s “direct involvement in, or subjection to, a significant traumatic experience or situation,” regardless of whether the incident was “extraordinary or unusual in comparison to” the person’s normal working conditions.

Nancy Grover is the president of NMG Consulting and the Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at
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Public Sector Risk

Police Controversies Affecting Coverage

Underwriters are taking a harder look at insurance terms and conditions for police departments in the wake of highly publicized deaths.
By: | May 5, 2015 • 5 min read
Special police forces with shield

Fatal police shootings of unarmed citizens and other recent examples of officers using lethal force in the U.S. are fueling controversy, making headlines and creating tension between law enforcement agencies and the communities they serve.

The national spotlight on officer-involved shootings hasn’t prompted carriers to dramatically change insurance pricing or policies for municipalities; however, risk managers and underwriters are absolutely paying careful attention.

“It leads the discussion, and we have to answer a lot more questions,” said John Chino, Irvine, Calif.-based area senior vice president and leader of Arthur J. Gallagher & Co.’s public entity practice.

Chino said that underwriters may be less likely to write a new law enforcement risk, and that police departments with any history of officer-involved shootings may not be a fit for some carriers.

Underwriters may be less likely to write a new law enforcement risk, and that police departments with any history of officer-involved shootings may not be a fit for some carriers.

“Some insurance companies may restrict limits of coverage, or you may be looking at an increase in deductibles,” said Bill Brouillard, executive vice president at HUB International in Wilmington, Mass.

He said the law enforcement sector as a whole saw claims activity increase and loss ratios creep up over several years driven by the types of claims most prevalent among police departments, including workers’ comp and losses involving patrol cars.

Instances of police using lethal force on unarmed suspects, while highly publicized, remain rare and are not causing a spike in claims.

Michael G. Fann, director of loss control, TML Risk Management, acknowledged that the police departments he works with are concerned that public opinion about law enforcement will grow increasingly negative and could erode their communities’ trust in police.

TML is a nonprofit insurance pool program sponsored by the Tennessee Municipal League to provide all lines of coverage to more than 500 towns, cities and municipal agencies.

“The subject of community engagement is important not only for police, but also for every aspect of city government.  We need to engage communities before they have an experience that would create a negative,” said Fann. “A first encounter with law enforcement in a neighborhood needs to not be when they’re [police] chasing me.”

“Law enforcement claims are going to be way more expensive to defend.” — John Chino, senior vice president and leader of Arthur J. Gallagher & Co.’s public entity practice

Reputational risk alone can be a factor in claims and losses, even in communities that haven’t experienced a shooting.

“Law enforcement claims are going to be way more expensive to defend,” said Chino, who recommended that his clients work with experienced attorneys to help determine whether to litigate or settle claims in a climate of negative public sentiment toward police.

“Clients will want to settle as quickly and quietly as they can because they’re not going to get a fair day in court.”

Chino’s municipal clients are budgeting in anticipation of settling more claims than they have in the recent past. Many set their claims administration reserves higher compared to 24 months ago, he said.

Fann counsels his insured on strategies to help their police departments “put credits in the bank,” or act to build a foundation of trust and emotional equity with the community, a relationship that will pay dividends when something negative happens.

Fann said that every law enforcement department can be more successful avoiding losses by focusing on policies, training, supervision and discipline for police officers.

Ken Wallentine, senior legal advisor and VP at Lexipol, a company that provides defensible policies and training for public safety organizations, said that some risk pools make it a condition of insurance coverage for cities to work with a consultant like Lexipol to set policies and train officers.

“First, make sure that rock-solid policies are in place.  You need ultimate confidence in your policies; make sure they are performing,” said Wallentine.  “Officer training should map to policies. Then verify that they were trained on the policies.”

Cities can pay for their loss control training programs with grants targeted for training, and with cost-sharing programs offered by reinsurers.

“As you enter into renewal, look for reinsurance and excess liability partners that know a lot about what works. If you get the police to implement training, reinsurers will help you pick the right training and will share the cost with you,” said Chino, who helps his clients navigate loss control issues, including the emerging issue of whether or not to require officers use body-worn cameras.

“The feeling from our risk managers is very positive,” said Chino.  “They would like to implement body-worn cameras because they believe it makes the officer accountable, and it can be used as a training device.”

Brouillard agreed that cameras can give officers a reason to think rather than just act, and he said that early research has found that use-of-force incidents as well as police misconduct claims decreased when cameras were worn.

Police departments are evaluating policies, procedures and the price tag for cameras along with the cost of specialized employees to coordinate the storage and usage of video evidence, said Brouillard.

Camera use also raises concerns about invasion of privacy and potentially creates a chilling effect on people who need the police’s help. A victim of crime or abuse may not call police if he or she fears being filmed during a crisis or moment of vulnerability.

Brokers and insurance experts advise police departments to apply solid risk management principles and best practices to all aspects of running their organizations, including their evaluation and adoption of new technology.

A strategic, long-term approach to loss control will serve cities and counties well no matter what types of risk management challenges are making headlines.

Meme Moore is a freelance writer based in Denver. She has nearly two decades of communications and writing experience. She can be reached at
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Sponsored Content by Helios

Mitigating Fraud, Waste, and Abuse of Opioid Medications

Proactive screening for fraud, waste and abuse situations is the best way to minimize their effects on opioid management.
By: | May 8, 2015 • 5 min read

There’s a fine line between instances of fraud, waste, and abuse. One of the key differences is intent and knowledge. Fraud is knowingly and willfully defrauding a health care benefit program for personal gain or profit. Each of the parties to a claim has opportunity and motive to commit fraud. For example, an injured worker might fill a prescription for pain medication only to sell it to a third party for profit. A prescriber might knowingly write prescriptions for certain pain medications in order to receive a “kickback” by the manufacturer.

Waste is overuse of services and misuse of resources resulting in unnecessary costs, whereas abuse is practices that are inconsistent with professional standards of care, leading to avoidable costs. In both situations, the wrongdoer may not realize the effects of their actions. Examples of waste include under-utilization of generics, either because of an injured worker’s request for brand name medication, or the prescriber writing for such. Examples of abusive behavior are an injured worker requesting refills too soon, and a prescriber billing for services that were not medically necessary.

Actions that Interfere with Opioid Management

Early intervention of potential fraud, waste, and abuse situations is the best way to mitigate its effects. By considering the total pharmacotherapy program of an injured worker, prescribing behaviors of physicians, and pharmacy dispensing patterns, opportunities to intervene, control, and correct behaviors that are counterproductive to treatment and increase costs become possible. Certain behaviors in each community are indicative of potential fraud, waste, and abuse situations. Through their identification, early intervention can begin.

Injured workers

  • Prescriber/Pharmacy Shopping – By going to different prescribers or pharmacies, an injured worker can acquire multiple prescriptions for opioids. They may be able to obtain “legitimate” prescriptions, as well as find those physicians who aren’t so diligent in their prescribing practices.
  • Utilizing Pill Mills – Pain clinics or pill mills are typically cash-only facilities that bypass physical exams, medical records, and x-rays and prescribe pain medications to anyone—no questions asked.
  • Beating the Urine Test – Injured workers can beat the urine drug test by using any of the multiple commercial products available in an attempt to mask results, or declaring religious/moral grounds as a refusal for taking the test. They may also take certain products known to deliver a false positive in order to show compliance. For example, using the over-the-counter Vicks® inhaler will show positive for amphetamines in an in-office test.
  • Renting Pills – When prescribers demand an injured worker submit to pill counts (random or not), he or she must bring in their prescription bottles. Rent-a-pill operations allow an injured worker to pay a fee to rent the pills needed for this upcoming office visit.
  • Forging or Altering Prescriptions –Today’s technology makes it easy to create and edit prescription pads. The phone number of the prescriber can be easily replaced with that of a friend for verification purposes. Injured workers can also take sheets from a prescription pad while at the physician’s office.


  • Over-Prescribing of Controlled Substances – By prescribing high amounts and dosages of opioids, a physician quickly becomes a go-to physician for injured workers seeking opioids.
  • Physician dispensing and compounded medication – By dispensing opioids from their office, a physician may benefit from the revenue generated by these medications, and may be prone to prescribe more of these medications for that reason. Additionally, a physician who prescribes compounded medications before a commercially available product is tried may have a financial relationship with a compounding pharmacy.
  • Historical Non-Compliance – Physicians who have exhibited potentially high-risk behavior in the past (e.g., sanctions, outlier prescribing patterns compared to their peers, reluctance or refusal to engage in peer-to-peer outreach) are likely to continue aberrant behavior.
  • Unnecessary Brand Utilization – Writing prescriptions for brand medication when a generic is available may be an indicator of potential fraud, waste, or abuse.
  • Unnecessary Diagnostic Procedures or Surgeries – A physician may require or recommend tests or procedures that are not typical or necessary for the treatment of the injury, which can be wasteful.
  • Billing for Services Not Provided – Since the injured worker is not financially responsible for his or her treatment, a physician may mistakenly, or knowingly, bill a payer for services not provided.


  • Compounded Medications – Compounded medications are often very costly, more so than other treatments. A pharmacy that dispenses compounded medications may have a financial arrangement with a prescriber.
  • Historical Non-Compliance – Like physicians, pharmacies with a history of non-compliance raise a red flag. In states with Prescription Drug Monitoring Programs (PDMPs), pharmacies who fail to consult this database prior to dispensing may be turning a blind eye to injured workers filling multiple prescriptions from multiple physicians.
  • Excessive Dispensing of Controlled Substances – Dispensing of a high number of controlled substances could be a sign of aberrant behavior, either on behalf of the pharmacy itself or that injured workers have found this pharmacy to be lenient in its processes.


Clinical Tools for Opioid Management

Once identified, acting on the potential situations of fraud, waste, and abuse should leverage all key stakeholders. Intervention approaches include notifying claims professionals, sending letters to prescribing physicians, performing urine drug testing, reviewing full medical records with peer-to-peer outreach, and referring to payer special investigative unit (SIU) resources. A program that integrates clinical strategies to identify aberrant behavior, alert stakeholders of potential issues, act through intervention, and monitor progress with the injured worker, prescriber, and pharmacy communities can prevent and resolve fraud, waste, and abuse situations.

Proactive Opioid Management Mitigates Fraud, Waste, and Abuse

Opioids can be used safely when properly monitored and controlled. By taking proactive measures to reduce fraud, waste, and abuse of opioids, payers improve injured worker safety and obtain more control over medication expenses. A Pharmacy Benefit Manager (PBM) can offer payers an effective opioid utilization strategy to identify, alert, intervene upon, and monitor potential aberrant behavior, providing a path to brighter outcomes for all.

This article was produced by Helios and not the Risk & Insurance® editorial team.

Helios brings the focus of workers’ compensation and auto no-fault Pharmacy Benefit Management, Ancillary, and Settlement Solutions back to where it belongs—the injured person. This comes with a passion and intensity on delivering value beyond just the transactional savings for which we excel. To learn how our creative and innovative tools, expertise, and industry leadership can help your business shine, visit
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