Why so many claims by Covid-19 workers ’companies are being rejected

Determining where a person contracted Covid-19 is proving to be a difficult legal conundrum. In many cases of workers ’compensation, carriers said people were likely to be infected during rest hours, while workers’ lawyers said their clients ’Covid-19 cases were directly related to unsafe work environments. .

Insurance carriers and business groups feared at the start of the pandemic that they would be overwhelmed by Covid-19-related worker claims. This concern intensified as more than a dozen states passed laws that gave some employees, including nurses and firefighters, the presumption of eligibility or access to mandatory coverage for workers without requiring them to accredit infections in the workplace.

Those fears were unfounded. Workers filed hundreds of thousands of virus-related claims in 2020, but these cases, according to state and industry data, were more than offset by a sharp drop in non-Covid-19 claims, as layoffs, shutdowns and remote work reduced accidents and work-related injuries.

The data also suggest that carriers deny a significant percentage of Covid-19-related claims, even in states with so-called presumptive eligibility rules. Through these measures, it is aimed at insurers to accept Covid-19-related claims from some front-line workers, skipping the usual step in which workers must prove that their accidents or illnesses have occurred while they worked.

The data show that not all claims filed are from front-line workers. carriers have received complaints from office workers, airline employees and people working in the arts and finance.

In the first three quarters of 2020, workers ’compensation and liability liabilities were 7.6% lower than in the same period in 2019, according to the National Compensation Insurance Council, a commercial group. This decrease is due, in part, to insurers receiving less than expected Covid-19-related claims for lengthy hospitalizations and deaths, said Donna Glenn, the group’s lead actuary.

Due to declining payments, some insurers are reducing the premiums they charge employers for coverage this year. However, the industry remains cautious and is concerned that so-called long-haul carriers — individuals with ongoing complications of Covid-19 infections — may receive significant and ongoing medical and salary replacement benefits, according to James Lynch, chief actuary of the insurance information. Institute, a trade association.

There are no comprehensive national data on the number of claims, payments, denials and acceptances related to Covid-19, but several states have released data on workers’ compensation payments. The figures suggest most Covid-19 claims have been relatively inexpensive for insurance companies, Lynch said. According to data from several states, claims have been denied at higher rates in states that do not give automatic eligibility to certain workers.

In Texas, where there is no presumption of eligibility for Covid-19, more than 32,000 Covid-19-related claims were filed as of Dec. 6. Insurers denied 45% of the people in which workers produced a positive Covid-19 test, according to the State Insurance Department. In California, which has a broad presumption law for certain lines of work, workers filed 93,470 Covid-19-related claims as of the end of December; 26% were denied.

In Florida, which received 29,400 workers’ compensation claims related to Covid-19 at the end of December, front-line workers who are state employees received a presumption of eligibility. Public data show that claims from state and local employees were accepted at much higher rates (with 22% denied) than claims from another group of state workers consisting primarily of private sector employees, in which approximately 56% of cases were denied. Of the claims paid in Florida through December, less than 2% cost carriers more than $ 10,000.

Claims arising from Covid-19 present a unique challenge. Most workers ’company claims involve injuries and accidents that occur in the workplace. Normally, an illness can only be covered if it is specific to a profession — for example, certain respiratory illnesses for firefighters — and not, for example, a case of flu acquired from a sick co-worker. There is still legal ambiguity as to whether Covid-19 qualifies as an “occupational disease” derived directly from some work environments.

With Covid-19, the source and cause of an infection must be determined on a case-by-case basis, said Malcolm Crosland, a attorney from Charleston, SC, and chairman of the Workers’ Injury Law and Advocacy Group, a professional association of lawyers. The bar for proving infection in the workplace is high.

“Your client should establish that there was no known source of exposure other than the workplace,” Crosland said.

This process is holding back many claims. Heather Kaplan, a workers’ compensation lawyer in Long Island, New York, has filed about 20 Covid-19-related claims. “All have been denied, including claims by medical workers,” he said. All claims must be fought in court hearings before the judges.

In late March, Daniel Avila Loma, an employee of meat packer JBS USA Holdings Inc., became ill and was taken to a hospital, where he was diagnosed with Covid-19 and sent home to quarantine for two weeks, said his son, Olivier. Ávila. Mr. Avila Loma returned to the hospital days later with worsening symptoms and died on April 29. Her death certificate lists Covid-19 and pneumonia as causes of death, her son said.

Mr. Avila Loma, who was about 60 years old, had worked at the JBS plant in Greeley, Colorado, for more than 25 years and hoped to retire within the year. In his last months at work, he was a sharpener, his son said.

“People would leave the knives, and he would sharpen them, and here we think he was exposed because there was a lot of contact with people from different lines,” he said.

The Greeley plant was cited in September by the Occupational Safety and Health Administration for failing to provide a secure workplace; several employees working at this plant died of Covid-19. In November, JBS removed 202 workers from the plant whom it considered vulnerable to coronavirus due to age and other factors, and paid them full wages and benefits during their stay away from work.

Mr. Avila Loma’s family filed a labor compensation claim to cover his lost wages and the loss of future earnings. JBS, which has self-insurance and is a unit of the Brazilian meat processing company JBS A,

JBSAY 1.95%

denied the claim. A hearing on the case is scheduled for spring.

“Mr. The last day of Avila at the Greeley beef production plant was March 25, which was the same day that the first case of Covid-19 was confirmed among the members of Greeley’s team. said the company. “We have covered all health expenses related to Covid-19 for workers and families enrolled in our health plan.”

JBS said it has implemented hundreds of security measures, including the installation of hospital ventilation systems at all facilities and the voluntary removal of vulnerable population groups with full pay and benefits.

Avila attorney Mack Babcock said efforts to pass a measure in Colorado to automatically protect certain front-line workers failed in the state legislature after insurers and business groups opposed it. He said that of the handful of Covid-19 cases his company is currently pursuing, all have been denied by companies or insurers.

Write to Lauren Weber to [email protected]