First responders rushing into burning buildings. Healthcare workers facing violent patients. Everyday employees experiencing workplace violence. As more states recognize PTSD as a compensable condition—even without physical injury—claims professionals face new challenges in managing these complex cases.
The Changing Landscape of Mental Health Claims
The workers’ compensation world continues to evolve, but meaningful coverage for mental health conditions still lags behind physical injuries. According to recent NIH research, while all 50 states provide coverage for physical-to-mental injuries (physical injury leading to mental health conditions), only 40 states cover mental-to-mental injuries (purely psychological trauma without physical injury).
Less than a third of states have proposed or enacted presumption of causation laws for mental health conditions to ease the burden of proof for first responders. This contrasts sharply with presumption laws for other conditions such as cancer, cardiovascular disease presumptions, and respiratory disease. In February 2025, a new state introduced a bill to create a PTSD assumption for first responders. Montana Senate Bill 394 is currently with the Finance and Claims Committee for review.
States with mental health presumptions often require specific qualifying conditions. Some mandate that the employee witness certain traumatic events, while others require proving the stress was “extraordinary and unusual” compared to normal working conditions—a challenging standard for first responders whose work is inherently stressful.
Understanding these complex requirements is essential for claims professionals, especially those handling claims for high-risk populations.
New York’s Mental Health Coverage Expansion
In a significant development, New York is expanding protections for workers experiencing mental injuries from work-related stress. The new legislation (S.755), which was signed into law on February 14, 2025 and takes effect 180 days post-signing, amends the workers’ compensation law regarding claims for mental injuries stemming from extraordinary work-related stress.
Key provisions of the New York bill include:
- Specifies that the board may not disallow claims from police officers, firefighters, emergency medical technicians, paramedics, emergency dispatchers and other emergency care providers for mental injuries from work-related emergencies based on a finding that the stress was “not greater than that which usually occurs in the normal work environment”
- Extends similar protections to all covered employees who file claims for post-traumatic stress disorder (PTSD), acute stress disorder, or major depressive disorder resulting from work-related stress
- Requires that medical evidence be based on criteria from the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or as adopted by the board
- Clarifies that employees must demonstrate the disorder arose from “extraordinary work-related stress attributable to a distinct work-related event or events directly related to the employment and occurring during the performance of the employee’s job duties”
This legislation represents a shift in recognizing the legitimacy of mental health injuries in the workplace, particularly for high-risk occupations where emotional and psychological trauma are occupational hazards.
California’s Proposed Healthcare Worker Presumptions
California is now considering similar expansions through Senate Bill 632, which would establish several important presumptions specifically for hospital employees who provide direct patient care in acute care settings. The bill represents a significant potential shift in workers’ compensation coverage for healthcare workers.
Key provisions of the California proposal include:
- Establishing a rebuttable presumption that post-traumatic stress injury for hospital employees providing direct patient care arises out of and in the course of employment
- Extending this PTSD presumption to cover employees for 3 calendar months for each full year of employment, up to 36 months after termination of employment
- Creating similar presumptions for other conditions including infectious diseases, cancer, musculoskeletal injuries, and respiratory diseases
- Recognizing the unique occupational hazards faced by healthcare workers, citing data that 28.4% of nurses had symptoms qualifying for a presumptive PTSD diagnosis
The bill’s findings specifically note that healthcare is one of the fastest-growing sectors, with women representing nearly 80 percent of the workforce and 90 percent of registered nurses being women. It argues that guaranteeing access to workers’ compensation for nurses will help address economic and social gender inequality, given the persistent wage gap women face.
This proposed legislation acknowledges that healthcare workers encounter many traumatic events in their work, including workplace violence, active shooter incidents, traumatic patient deaths, and repeated exposure to patients’ trauma. The bill recognizes these stressors as occupational hazards that warrant presumptive coverage.
Understanding PTSD: A Growing Occupational Health Concern
Post-traumatic stress disorder goes far beyond normal workplace stress. It’s a serious mental health condition where trauma victims experience:
- Intrusive thoughts and flashbacks of traumatic events
- Recurring nightmares and sleep disturbances
- Avoidance of situations that trigger memories
- Heightened nervousness and startle responses
- Difficulty functioning in work and personal life
First responders, such as firefighters, police officers and EMTs, are particularly vulnerable. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), an estimated 30% of all first responders develop behavioral health conditions such as depression and PTSD, compared with 20 percent in the general population. Studies show up to 32% of first responders experience PTSD, with nearly half of firefighters reporting suicidal thoughts.
Other employee groups at risk for PTSD include healthcare and social workers, mental health providers, as well as employees experiencing workplace violence, such as employees working within the Department of Corrections, or those faced with armed robberies or active shooters.
Medication Management
Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are typically the first medications prescribed for PTSD:
- Sertraline (Zoloft)
- Paroxetine (Paxil)
- Fluoxetine (Prozac)
- Venlafaxine (Effexor)
These medications help regulate mood and are generally well-tolerated, making them appropriate starting points for treatment. Other off-label medications may also be prescribed to treat PTSD.
Red Flags in Medication Management
Claims professionals should watch for concerning medication patterns:
- Benzodiazepines and opioids should generally be avoided in PTSD patients, as they can worsen symptoms and create dependency issues
- Claims showing only medication therapy without psychological counseling may indicate inadequate treatment
- Multiple psychiatric medications without clear documentation of improvement warrant review
Beyond Medications: Comprehensive Treatment Approaches
Medication alone is rarely sufficient for PTSD recovery. Effective claims management should consider:
- Cognitive Behavioral Therapy (CBT)
- Exposure therapy or stress inoculation training, where appropriate
- Regular psychiatric evaluations document treatment response
- Return-to-work planning that contemplates both medication effects and psychological readiness
Conclusion: The Path Forward
The expansion of mental health coverage in workers’ compensation signals a growing understanding of the legitimate nature of psychological workplace injuries. Effective PTSD claims management requires a multifaceted approach that goes beyond basic medication oversight. For organizations dealing with high-risk populations, developing specialized mental health management protocols is essential for controlling costs while ensuring injured workers receive appropriate care.