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COVID Compensability Conundrum – Who’s Covering What?


COVID Compensability Conundrum – Coronavirus Causing Workers Comp Claims?

Adjusters Will Deal With COVID Claims 

The COVID Compensability Conundrum will arrive later this year when workers comp claims adjusters have to make difficult and complicated claim decisions.

NCCI COVID Compensability Conundrum-19 Rotovirus simulation
Wikimedia – See previous author info

Most states have a disease statute.  Not many states include personal sensitivity claims in their rules and regulations.

One of the most prevalent difficult workers’ compensation claims decisions involves the adjuster determining whether or not the alleged work comp injury or disease came from a source that exposed the claimant to a higher degree of susceptibility than just being in the general public.   

This type of claim causes much consternation between the adjuster and the injured employee when the file is denied due to the exposure not being more at work than the claimant would find in the general public.

A cold or the flu was never accepted by any claims department that I am familiar with regardless of the job title.

Many members of the worker’s comp press published articles over the last three weeks pertaining to First Responder coverage.   Governors are likely to order coverage for First Responders.

Exposed Workers

How about these workers:

Nurse adjusting COVID Compensability mask
  • Grocery store workers
  • Grocery delivery
  • Pharmacy staff
  • Bank staff – handling cash
  • Restaurant employees – drive-thru or takeout
  • Post office
  • Shipping services – UPS, FedEx
  • Home care workers

As one can see, the list goes on and on.  Determining where the exposure occurred is complicated at best.

The adjuster’s job will become even more difficult.  How would an adjuster make this COVID Compensability Conundrum decision have more fortitude?

Adjuster Investigation on COVID Compensability

The five main investigative tools for adjusters are:

  1. Job Description – did their job expose the claimant more to COVID than being in the general public?  Is there really a general public now with the lockdown orders?
  2. Recorded interview – #1 above should be covered very well here
  3. Treating Doctor’s notes – the person has to have a COVID diagnosis – did the physician relate it into the job – extremely important.
  4. First Report of Injury – an often overlooked investigative tool
  5. Initial discussion with the employer – for obvious reasons


Do not be surprised if the Governors /Insurance Commissioners create orders to pay for COVID work comp claims

As we all sit home and wait to go back to the office, or work harder telecommuting – I thought this quick article on the COVID Compensability Conundrum would cause claims departments to start thinking about these types of claims as more people are tested over the next few weeks.


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James J Moore - Workers Comp Expert

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Management Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications


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