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: 

  • 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?   

Check This Out- A Great Related Post from J&L Workers Comp Claims Processing Manual Needs ASAP Theme

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. 

This blog post is provided by James Moore, AIC, MBA, ChFC, ARM, and is republished with permission from J&L Risk Management Consultants. Visit the full website at

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