As heat exposure becomes a more visible workplace risk, workers compensation claims professionals say disputes are not always about whether a worker suffered a classic heat illness, but whether heat contributed to another medical event or injury.
That question is complicating causation reviews in claims involving fainting, falls, cardiac symptoms, dehydration or other events that may not initially be coded as heat-related.
Compensability often turns on whether the heat exposure occurred in the course and scope of employment and whether job conditions materially contributed to the illness or injury. That can be straightforward when a worker falls ill while working outdoors on a high-heat day. It can be more complicated when dehydration, off-duty activity, medications or underlying health conditions are involved, they say.
If a worker is outside the course and scope of employment — such as during a commute — the claim generally would not be compensable, said Rich Ives, Hartford, Connecticut-based senior vice president of business insurance claim for Travelers. But if the worker is performing job duties and an environmental condition causes the injury or illness, “you will most likely find that to be a compensable loss,” he said.
Causation can be difficult to determine in heat claims, particularly when symptoms may also be tied to an underlying condition, said Jim Kenney, Sunrise, Florida-based senior vice president of medical services at Broadspire.
“You have to remember that they’ll always look for causality,” he said. “Did it happen within the course and scope of employment? … If somebody was at work and they were out there and they were sweating and they weren’t drinking anything and they fainted, it very well could be caused from heat stroke or it could be caused by an underlying condition. So causality is kind of a sticky point.”
Preexisting conditions do not necessarily bar a claim, experts said, but they can complicate the analysis. Conditions such as diabetes, cardiovascular disease, kidney disease, obesity, pregnancy and certain medications can reduce heat tolerance. Claims adjusters may need medical records, witness statements, weather data, job descriptions, information on personal protective equipment and details about hydration, breaks and acclimatization.
The first priority is medical response, with compensability reviewed later, said Suzanne Zdrodowski, Madison, Wisconsin-based assistant vice president of clinical operations at Sedgwick.
“You don’t want to necessarily treat it any different,” she said. “It’s how quick you can recognize the symptoms and how quick you can act on it.”
After a worker is stabilized, an examiner reviews medical records, interviews and facts surrounding the event to determine whether a job caused or materially contributed to heat exposure, she said.
Heat and weather have historically not been captured as standard claims data points, particularly when a worker reports a fall or other injury rather than a heat illness, said Tammy Bradley, Birmingham, Alabama-based vice president of clinical strategies and market insights at Enlyte.
“Think about what goes on a first notice of loss,” she said. “It’s body type, nature of injury, age … what happened, what were they doing? But the fact that someone documented that it was 115 degrees inside the building? No.”
That may change as more employers and claims organizations look for ways to identify heat as a contributing factor, she said.
Heat-related claims may also surface through subrogation, experts said.
If a worker seeks treatment through group health and later indicates the event happened at work, the health insurer may seek reimbursement from the workers comp insurer.
Most workplace heat claims are likely routed correctly at intake, but subrogation remains possible if a claim is paid under the wrong coverage, Mr. Kenney said.
“Everybody’s looking to control costs,” he said. “You see subrogation on any opportunity, sometimes worthwhile, sometimes not.”
Heat illnesses and fatalities may also be undercounted or misclassified, said Laura Oslund, Seattle-based senior risk services consultant at Sedgwick. A worker who suffers a heat-related medical event after leaving work may not immediately connect the condition to workplace exposure, and some serious illnesses may be classified as heart attacks or strokes rather than heat-related events.
“The numbers … are clearly undercounted, because I’m sure a lot of times they’re misclassified as like a heart attack,” she said.
Ms. Oslund said the focus on heat has shifted in part because employers and safety professionals are recognizing that heat risk is not limited to outdoor work.
“For the outdoors, that’s been a risk for quite some time,” she said. “I think really the focus today is people realizing that it’s a risk within the indoor operations as well.”
Indoor heat can be harder to recognize because workers and employers may not see obvious warning signs, such as direct sun exposure, she said. Manufacturing plants, warehouses and other indoor environments can present heat hazards that may go unnoticed because employees are exposed to them every day.
This article was first published in Business Insurance
