When an employee experiences a traumatic event at work, workers’ compensation coverage is probably the last thing on your mind. But knowing how post-traumatic stress disorder is defined and covered in your state can help you make sure your employee gets needed help.

For PTSD to be covered by workers’ compensation, it must meet the criteria as described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, and be diagnosed by a psychologist or psychiatrist.

By definition, symptoms must last or start a month or more after the event to be considered PTSD. Symptoms that last less than a month are considered acute stress disorder. This nuance is important when it comes to how different states handle PTSD claims.

Some states specifically address PTSD in their workers’ compensation laws. In other states, whether PTSD is covered depends on what caused it and whether the state recognizes that event as a work injury.

If the event that led to PTSD was physical, most states will recognize that as a physical/mental injury (that is, a mental injury caused by physical injury) and treatment for PTSD will be compensable. If the employee was involved in a traumatic event, but there was no physical injury, some states may not recognize PTSD as a claim. This is referred to as a mental/mental injury.

Here are the specifics on PTSD in SFM’s core states:

• Minnesota
  PTSD is specifically addressed in the statute. If an employee is diagnosed with PTSD by a licensed physician or psychologist and the employee meets the Diagnostic and Statistical Manual of Mental Disorders criteria, the claim is covered by workers’ compensation benefits. This is the only type of mental/mental claim recognized in Minnesota. If PTSD is diagnosed as arising from a physical injury, that would be compensable in Minnesota as a physical/mental claim.

  For injuries occurring after January 1, 2019, it will be a presumption that PTSD in first responders is compensable under workers’ compensation, absent preexisting history and limited statutory exceptions. PTSD claimed due to job performance issues, such as demotions and layoffs, is not compensable.

• Wisconsin
  PTSD is not specifically addressed in the statute. Mental/mental injuries can potentially be compensable if the circumstances causing the injury arise from extraordinary stress. It must be a far greater stress than the expected emotional strain that employees encounter daily without serious mental injury.
• Iowa
  Mental/mental injuries are recognized, but in order to be compensable under Iowa law, the work condition and circumstances lead­ing to the mental condition must exceed that which is typically experienced by peers in that same profession. PTSD may be compensable without any physical injury to the body under these circumstances.
• Nebraska
  Mental/mental injuries are not compensable in Nebraska, so a diagnosis of PTSD without any physical injury would typically not be covered. If there is a physical injury to the body and PTSD is a condition that is a result of that injury, it could be compensable as a physical/mental injury.

  However, first responders are an exception. PTSD could be compensable as a mental/mental injury for first responders who are exposed to extraordinary and un­usual stimuli in comparison to normal conditions of their employment. Nebraska statute defines first responders as sheriffs, deputy sheriffs, police officers, state patrol troopers, volunteer or paid firefighters, emer­­gency medical technicians and paramedics.

• South Dakota
  South Dakota does not cover mental/mental injuries. There must be a physical injury to the body. If an employee sustains a physical injury and claims PTSD as a consequential injury, then it could be compensable.

Intervene early to help employees who’ve experienced trauma

Although PTSD cannot be diagnosed until 30 days after a traumatic event, you shouldn’t wait that long to reach out to your employee. Early intervention can prevent situational anxiety from progressing to PTSD. Encourage any employee who may be susceptible to seek help through your employee assistance program, SFM’s Injured Worker and Family Assistance Program or from a psychologist or psychiatrist.

“If someone has experienced trauma, be it physical or mental, coping skills for them to be more resilient so they can manage their stress and anxiety is what’s going to get them better,” said Director of Medical Services Ceil Jung, RN, BSN, CCM. “Treatment is typically cognitive behavioral therapy (CBT). Symptoms can usually be effectively managed to restore the individual to normal functioning.”

SFM’s claims representatives spend all day managing workers’ compensation claims. They coordinate with injured workers, employers and medical providers. Many of them have decades of experience in the field. So, when we asked them to give us their top tips for employers, they delivered.

Here’s what the claims adjusters said:

• When hiring, include the physical demands of the job in the job description. Have prospective candidates sign off on the descriptions to signify that they can perform the essential functions of the job. Pre-employment physicals and criminal background checks are also important.
• Always investigate after an injury. Document how, when and where the accident occurred. Talk with the injured employee and witnesses, and take photos. If you have surveillance cameras in the area, let the claims representative know. Then figure out how to prevent it from happening again. This information also helps claims representatives to verify what they are told by the injured worker.
• When bringing employees back to work, work together with the employee to look for ways they can perform their job within their medical restrictions. Your claims representative can also provide suggestions and resources if needed. Require the employee and supervisor to commit to working within those restrictions. It’s always good to put it in writing and get everyone to sign off.
• Be sure to tell your claims representative right away when an employee starts needing time off for a work injury and when the employee returns to work so that benefit payments are on time and correct.
• Focus on building strong relationships between employees and direct supervisors.
• Continue communicating with injured employees, even if they are totally disabled and unable to return to work. Keeping the lines of communication open and letting employees know you care about them is really important.
• Address disciplinary issues with staff right away. If you don’t, and the employee is injured, these issues become much more difficult to deal with.
• If an employee is injured in a work-related automobile accident, be sure to send the claim to both your workers’ compensation and auto insurer. If the injury is work-related, workers’ compensation provides primary coverage, and your insurer will pursue recovery from an at-fault party.
• Make a copy of any paperwork an injured worker brings in, especially any doctor’s reports, and forward to the claims representative.
• Report all claims right away.
• Allow your claims representative to deliver hard-to-hear news to the injured worker versus doing it yourself. That helps you maintain a positive relationship with the employee, which is more conducive to a speedy and effective return to work.

 For more tips, read four things you need to do after an employee is injured.

This is not intended to serve as legal advice for individual fact-specific legal cases or as a legal basis for your employment practices.

Fast, accurate injury reporting can reduce frustration for everyone involved.

Sometimes it can even reduce costs by preventing:

• State penalties
• Litigation
• Delayed return-to-work
• Low employee morale
• Unnecessary medical costs

Following are some of the most common reporting mistakes we see, and ways you can easily avoid them:

• Not indicating that an employee is missing work due to a work injury.
  As soon as your employee begins losing time from work due to the injury, let your claims representative know, so the employee receives wage-replacement benefits on time. Failing to do this can lead to state penalties and financial hardship for the employee.
• Reporting late.
  As soon as any supervisor, manager or claims coordinator becomes aware of an injury, the clock starts ticking toward your state’s deadline to determine whether the employee is due workers’ compensation benefits. Missing the deadline can result in significant state penalties. Reporting right away gives your claims representative enough time to investigate the injury before the deadline. See the How to report a work injury page for details on how to report.
• Incomplete forms.
  If you choose to report your claim by filling out a form, leaving off important information can delay processing of a claim. Especially important details include: Social Security number and date of birth of the employee, date of injury, date of first day of lost time, date employer was notified about injury, and contact information.
• Communications breakdowns.
  Make sure employees and supervisors understand the process for reporting a work injury at your organization. Delays in reporting injuries sometimes occur because employees simply don’t know who to tell if they are injured.
• Including sensitive information in first reports.
  In some states, including Minnesota, the injured employee is entitled by law to receive a copy of the First Report of Injury. If you suspect fraud, or have other sensitive information about the incident, report it to your claims representative separately or report your concerns through our website. If you report through the SFM Work Injury Hotline, you can call or email your claims representative about your concerns. If you report the injury using a form, you can write it on a separate piece of paper and attach it to the first report. If you report online, you can type it in the confidential comments box on SFM’s online First Report of Injury.
• Not reporting questionable claims.
  Sometimes employers don’t report an injury because they think it is suspicious, or not serious enough to report. This is a violation of state laws, which require the employer to report any injury claimed by an employee. Instead, report all injuries, but let your claims representative know about your concerns. Your claims representative will investigate the claim and its circumstances.
• Sending a First Report of Injury to your agent.
  Please report workers’ compensation claims directly to us. Sending them to your agent can delay our receipt of the report, which can hamper our ability to investigate and respond promptly to the claim.
• Filing in the wrong state.
  For employers with multiple locations, sometimes there’s confusion over which state to file the claim in. Due to the differences in states’ workers’ compensation laws, this can sometimes be difficult to determine. A good rule of thumb is to file in the state where the employee was hired or typically works. When in doubt, it’s still best to make the report right away and let your claims representative know that you have concerns.

This post was originally published on June 18, 2013, and updated on June 15, 2021.

This is not intended to serve as legal advice for individual fact-specific legal cases or as a legal basis for your employment practices.

By Tom Davern, Esq., Senior Defense Counsel with SFM’s in-house law firm, and Julie Bischoff, Senior Subrogation and Special Investigations Representative

When one of your employees is injured in the course and scope of employment and a negligent third party bears some responsibility, we can sometimes recover a portion or all of the workers’ compensation claim costs from the responsible party through subrogation.

Each of SFM’s core states have different workers’ compensation subrogation laws, but the basic principles are the same across the board. If a third party’s negligence causes a work injury to some significant degree, there is a possible subrogation claim. The employer and insurer have to prove negligence, causation and damages.

When we recover claim costs, it lowers the impact that the claim has on future workers’ compensation premiums by mitigating the hit to the employer’s experience modification factor (e-mod). In 2020, our Subrogation Team recovered more than $1.5 million. In many cases, SFM recovers 100% of what was paid on the claim. In fact, full recovery was received on over 50% of the subrogation claims in 2020. A complete recovery is most likely when there is no liability dispute and the injury is not serious enough to allow or motivate an employee to pursue a personal injury claim. If the employee pursues a claim for damages against the third party, it usually results in a partial recovery for the employer and insurer.

Common recovery scenarios

Motor vehicle accidents, slip-and-fall injuries and dog bites are just three types of claims where we can often make subrogation recoveries.

For example, if a pizza delivery driver is hit by a drunk driver, we may be able to recover the workers’ compensation benefits paid from the at-fault driver’s insurer.

If there is provable negligence, slip-and-fall claims can result in a subrogation recovery; however, these have to be carefully analyzed on a case-by-case basis. There is not going to be a viable claim if a slip and fall happened in a parking lot during a blizzard, but if a vendor spilled oil in a hallway and failed to clean it up, there may be a claim.

If a dog bites a home health care worker or delivery person at a customer’s home, we may be able to recover costs from the individual’s homeowners or rental insurance policy. SFM also pursues product liability claims, medical malpractice and restitution in criminal matters.

How employers can help

If you have a claim that has recovery potential, your claims representative or someone from our Subrogation Team may reach out for assistance in the investigation. It is helpful to gather and preserve any available evidence in cases that may have recovery potential.

Anytime you think a third party could be responsible for a work injury, let your claims representative know. SFM aggressively pursues recoveries on behalf of our policyholders when another party is at fault.

Common requests for subrogation claims

• Motor vehicle accident: Police report, photographs of the property damage or scene, third-party driver/insurance information, and video of the incident (if available)
• Dog bites: Name and address of the dog owner and police or incident report
• Slip, trip and fall: Photographs of the area of the fall, any available video (we also recommend reporting the incident to the property owner)
• Assault: Whether criminal charges were filed, and if so, the name of the assailant
• Product liability claims: Secure the product and provide owner manuals, maintenance records, purchase receipts and manufacturer information (for equipment malfunctions, we recommend also taking photos and keeping any broken equipment)

If you want to lower your workers’ compensation premium, it’s worth learning about a little number called your e-mod.

Why? Because your premium is determined, in part, by your e-mod — and it’s one factor you can actually manage.

So what does e-mod stand for?

E-mod is short for experience modifier or experience modification factor.

The experience modification factor is a multiplier used to calculate your workers’ compensation premium. It shows how your organization’s workers’ compensation claims experience compares to other businesses similar in size and types of jobs.

If your claims history is average among similar businesses, your e-mod will be 1.0. If your e-mod is:

• above 1.0 it means your business’ claims history is worse than your peers.
• below 1.0 it means your business’ claims history is better than your peers.

An e-mod less than 1.0 directly reduces the premium amount you pay. The lower your e-mod, the greater the reduction.

That’s the short answer. The longer answer is valuable to know if you want to really take control of your workers’ compensation costs.

What goes into the e-mod calculation?

The e-mod usually takes into account three years of claims history, excluding the most recent policy year. For example, the e-mod for a policy period beginning January 1, 2023, includes claim costs for the policy periods beginning:

• January 1, 2021
• January 1, 2020
• January 1, 2019

Who determines your e-mod?

A state or national rating bureau — not your insurer — calculates experience modification factors.

Depending on your state, either your state rating bureau (such as the Minnesota Workers’ Compensation Insurers Association or the Wisconsin Workers’ Compensation Rating Bureau) or the National Council on Compensation Insurance determines your e-mod. These data collection organizations use statewide claim data to calculate expected losses for different types of operations.

They also calculate individual employ­ers’ e-mods using the claims cost data reported by insurers.

Your data collection organization recalculates your e-mod each year about 90 days prior to your policy renewal date and reports it to you and your workers’ compensation insurer.

Who gets assigned an e-mod?

Not every business is large enough to have an e-mod.

Your workers’ compensation premium has to be above a certain dollar threshold specified by your state before your organization will be assigned an e-mod. This minimum premium amount is usually around $3,000-$7,000.

Which claims costs are excluded from the e-mod?

Not all claims costs are included in the e-mod calculation.

If a claim is medical-only (meaning the employee doesn’t miss any work time due to the injury, or returns to work within the state waiting period), only 30 percent of the claim costs are included in the e-mod calculation. That’s one of the many reasons for a strong return-to-work program.

If the claim is larger, typically involving lost time, there is a discounted rate for losses over a certain amount. This is known as the split point, and is set by each state. For example, in Minnesota in 2023, the split point is $18,500. That means that when the e-mod is calculated, less weight is given to a claim’s dollars over $18,500.

Where to find your e-mod

If your organization is large enough to have an experience modifier and you’re an SFM policyholder, you can find it in three places.

1. The official notice you receive from your rating bureau each year prior to your policy renewal date
2. Your SFM policy information page
3. In CompOnline under the “Policy” tab, on the “Policy information” screen

How to calculate your e-mod yourself

You may want to try to figure out what your e-mod will be following a significant claim, or test out “what if” scenarios.

Each state rating agency calculates e-mods differently, so this isn’t always easy.

The Minnesota Workers’ Compensation Insurers Association offers a free Minnesota Experience Modification calculator . The Wisconsin Compensation Rating Bureau and National Council on Compensation Insurance (rating agency for Iowa, Nebraska, Kansas and South Dakota) offer similar tools for a fee.

To learn more about the e-mod calculation formula in your state, see the following resources:

• Minnesota: Experience rating frequently asked questions
• Iowa, Nebraska, Kansas and South Dakota: ABCs of Experience Rating brochure

Keeping an eye on your e-mod is a good habit that will help you understand and then work on lowering your workers’ compensation premium.

Learn more in SFM’s E-mods CompTalk .