Psychological Injuries in Workers’ Comp: A Patchwork of State Approaches

In recent years, mental health has become a growing focus in the workplace. Employers and policymakers alike are paying closer attention to how psychological well-being intersects with job performance, safety and long-term employee health.

Yet when it comes to workers’ compensation, psychological injuries occupy one of the most complex and inconsistently defined areas of the law. These claims are often emotionally charged, medically nuanced and legally challenging to prove. Unlike physical injuries, where cause and effect are usually clear, mental injuries often depend on subjective experience, medical interpretation and the unique statutory framework of each state.

Since there is no federal oversight of workers’ comp, every state has developed its own laws and evidentiary standards for handling psychological injury claims. As a result, what qualifies as a compensable mental injury in one jurisdiction might be completely excluded in another, and this lack of uniformity creates significant challenges for employers, insurers and employees. Generally, mental injury claims are divided into three categories based on the cause of the condition.

The first—and most commonly compensable—are psychological injuries that stem from a physical on-the-job accident. These are often referred to as “physical-mental” injuries. For example, if an employee suffers a serious back injury after a fall at work and later develops anxiety or depression related to chronic pain or loss of mobility, that would be considered a physical-to-mental injury.

The second category, “mental-physical” injuries, occurs when psychological stress from employment results in a physical condition. For instance, if an employee experiences sustained work-related stress and later develops high blood pressure or gastrointestinal issues, that would qualify as a mental-to-physical injury.

The last—and least likely—category to be compensable in most states involves “mental-mental” injuries. These transpire when a purely psychological stimulus rather than a physical one causes psychological harm, such as post-traumatic stress disorder, depression or anxiety. This might occur when an employee witnesses a traumatic workplace event such as a violent incident or the sudden death of a coworker and subsequently develops PTSD or another mental health disorder.

States have taken varying approaches to handling these psychological claims, whether they stem from a physical injury or a traumatic worksite experience. Most states recognize “physical-mental” injuries as compensable, meaning employees who sustain psychological injuries that arise from a physical injury are eligible for workers’ comp benefits. For example, in Georgia, the case Hanson Buick v. Chatham established that a psychological injury must arise out of a physical injury or a “discernible physical occurrence” to be compensable. It also states that while a physical blow or visible wound is not always required, there must be some physical occurrence such as a fall, a sudden loud noise or exposure to harmful substances that contributes to or triggers the psychological condition.

Similarly, Florida law limits psychological injury compensation to cases in which the mental condition arises directly from a physical, work-related injury and is supported by clear and convincing medical evidence (Fla. Stat. § 440.093). “Stress-only” claims are excluded, meaning that an employee cannot receive benefits for conditions like anxiety or depression if they result solely from work-related stress without any accompanying physical harm. Florida law also requires that the physical injury be the “major contributing cause” of the psychological injury, meaning it must account for at least 50% of the resulting condition. However, the law has been expanded to allow first responders to bring claims for mental-only injuries (Fla. Stat. § 112.1815(5)(a)).

A majority of states also recognize “mental-physical” injuries in which psychological stress results in a physical manifestation. In Minnesota, for example, the statute provides that “physical stimulus resulting in mental injury and mental stimulus resulting in physical injury shall remain compensable” (Minn. Stat. § 176.011). However, Minnesota law specifically excludes claims resulting from personnel actions such as disciplinary measures, performance evaluations, demotions or terminations if the employer acted in good faith. New Hampshire follows a similar approach, allowing compensation for work-related mental disorders only if they directly cause a physical manifestation such as ulcers, high blood pressure or heart attacks and are not the result of routine workplace stress or legitimate management decisions (N.H. Rev. Stat. 281-A:2).

When it comes to “mental-mental” claims, states diverge significantly. Some states deny these claims entirely while others allow coverage under narrowly defined circumstances. Generally, “ordinary work stress” is not enough to make a claim compensable in any state. However, Delaware takes a more inclusive approach. Its Supreme Court held in State v. Cephas that a mental injury can be compensable even when it results from gradual, cumulative stress rather than a single traumatic event and without any physical trauma. The employee must still provide objective proof that work-related stress was a substantial cause of the disabling condition. Still, Delaware case law reflects a more progressive view of coverage for psychological injuries than most other states.

Other jurisdictions are considerably stricter. Alaska law specifies that workers’ comp benefits for mental injuries caused by stress are only payable if the employee can demonstrate that the stress was “extraordinary and unusual” compared to that experienced by others in similar positions and that this stress was the predominant cause of the mental condition (Alaska Stat. § 23.30.395). Arizona has also set a high bar for mental-only claims. In Timothy Matthews v. The Industrial Commission of Arizona, a leading case involving a Tucson police officer who developed PTSD after responding to a suicide scene, the Arizona Supreme Court ruled that mental health injuries without corresponding physical trauma are compensable only when the employee faces “unusual, unexpected, or extraordinary” stress. Since responding to violent incidents was deemed a normal part of police work, the court denied coverage under its workers’ compensation laws.

Nonetheless, many states have carved out exceptions for first responders in recognition of the unique and often traumatic nature of their work. Connecticut, for instance, limits eligibility for mental-only claims to certain occupations, including police officers, firefighters, EMS personnel, correctional officers, telecommunicators and health care providers (Conn. Gen. Stat. § 31-275). Texas law explicitly provides that PTSD suffered by a first responder is a compensable injury, provided specific statutory conditions are met (Tex. Labor Code § 504.019). Other states have adopted similar carveouts for emergency personnel but continue to exclude coverage of mental-only claims for different types of workers who are not first responders.

It is essential to consider a state’s specific provisions when prosecuting, defending against or assessing this type of claim. From the employee’s standpoint, alleging a psychological injury can be daunting. The burden of proof lies squarely with the claimant, who must demonstrate through credible medical evidence that a mental disorder exists, that it arose out of and in the course of employment, and that it meets the specific statutory standards for compensability in their state. Psychological conditions often result from a combination of work-related and non-work-related factors, making it challenging to draw a clear causal connection to the workplace. Claimants typically must provide detailed medical records, psychological evaluations and expert testimony to substantiate both the existence of the disorder and its work-related cause. The absence of visible injuries or objective diagnostic tests often makes these claims more difficult to substantiate compared to physical injuries.

For employers defending against psychological injury claims, a meticulous review of medical and employment history is critical. In many cases, employers should examine the employee’s prior psychiatric records, history of personal stressors and overall job performance to assess whether the alleged condition is truly work-related. Independent medical evaluations conducted by board-certified psychiatrists or psychologists can provide an impartial assessment of diagnosis, causation and prognosis. Employers and insurers may also consider workplace policies, employee assistance programs and stress management initiatives as mitigating factors in the defense of these claims.

From the insurer’s perspective, psychological injury claims present unique underwriting and claims management challenges. Insurers must navigate varying state standards, assess complex medical evidence and manage the increased potential for subjective interpretations of mental health symptoms. Adjusters handling these cases should evaluate both medical and legal elements of the claim, including whether the alleged injury meets statutory definitions and whether medical evidence satisfies the burden of proof. Reliance on multidisciplinary collaboration between claims professionals, medical experts and legal counsel is essential when assessing the validity of these claims.

As awareness of mental health grows across society, the legal landscape surrounding psychological injuries in workers’ comp continues to evolve. States are gradually expanding protections for certain classes of workers, particularly first responders, and some state courts are becoming more open to considering cumulative psychological harm rather than limiting coverage to single traumatic events. However, the absence of federal standards means the patchwork of state laws will persist, with some jurisdictions maintaining strict thresholds and others taking a more progressive stance.

In the years ahead, coverage of psychological injury claims in workers’ comp will likely remain a dynamic and debated area of the law. As the workforce continues to prioritize mental health and societal attitudes shift toward greater recognition of psychological well-being, policymakers and courts will continue to refine the balance between protecting workers and preserving the integrity of the compensation system. For insurance and claims professionals, staying informed about these developments is prudent and necessary to navigate the increasingly complex intersection of mental health and workers’ compensation law.

Osborne is an associate attorney at Swift Currie in Atlanta, where she defends employers and insurers against workers’ comp claims throughout Georgia. Email: shantalia.osborne@swiftcurrie.com.