Managing the Complexities of Cancer, Heart, and Lung Claims

Cancer, heart, and lung claims are among the most complex claims in workers’ compensation. They may involve long treatment timelines, evolving medical technology, highly specialized medical care providers, and state-specific presumption laws. Successful management of these claims often depends on early collaboration, informed oversight, consistent communication, and proactive long-term planning.

“The prevalence and complexity of cancer, heart, and lung claims appears to be growing, particularly among first responders and other workers covered by expanding presumption laws,” said Tanya Parker, Assistant Vice President – Client Engagement at Safety National. “Considering the industries most likely to be affected, like firefighters and law enforcement where colleagues often form close bonds, these types of claims can be deeply personal. Claims can last years or even decades and may involve treatments outside the experience of many claims professionals, so it becomes critically important to lean on the network of stakeholders involved in the process.”

Here, we review general strategies to support claims teams in managing medical complexity, costs, and communication while supporting the injured worker.

Collaborating with the Right Team

Early engagement of appropriate stakeholders involved with a cancer, heart, or lung claim can deeply impact its long-term management. Depending on the facts of the claim, this can involve the employer, claims adjuster, nurse case manager, defense counsel, and appropriate medical resources. There are often many specialists involved in these types of claims due to medical complexity, but providers, such as oncologists, pulmonologists, cardiologists, and transplant teams, may be less familiar with the workers’ compensation system. The nurse case manager can help communicate the process and coordinate information among stakeholders.

Additionally, claims managers and nurses assigned to the claim should have appropriate experience with complex or catastrophic claims because of the potential duration and severity of the claim. When medical records are difficult to obtain or treatment plans are hard to interpret, a field nurse case manager can support the claims team by helping gather information and facilitate communication among authorized parties.

Understanding the Medical and Legal Landscape

Every complex claim can vary in its long-term outlook based on a variety of factors, including pre-existing conditions, biopsychosocial factors, and the jurisdiction in which the claim arises. Understanding an injured worker’s continuum of care should be a priority for all stakeholders. Does the team understand the diagnosis and current treatment plan, based on available medical information? Where is the worker in the treatment and recovery stages? Have potential future needs, such as home modifications or medical equipment, been evaluated? Further examination of comorbidities and mental health may also play a significant role in an injured worker’s recovery and should be considered early in the claim, as appropriate.

Presumption laws, which vary across states and occupations, can affect a claim’s compensability, particularly for firefighters, police officers, front-line responders, and certain other covered workers. Many states have enacted cancer presumption laws for firefighters and first responders, with some jurisdictions also providing presumptions related to cardiovascular disease, respiratory disease, or infectious disease. Defense counsel should be familiar with applicable presumption laws and be able to provide jurisdiction-specific guidance during the investigation and settlement evaluation stages, as the legal landscape continues to evolve around these laws.

Managing Treatment Complexity and Cost

Cancer, heart, and lung claims can involve treatments that some stakeholders may be unfamiliar with, such as chemotherapy, radiation, biologics, and immunotherapy. These treatments may help avoid a potential organ transplant or improve an injured worker’s prognosis, but they can also carry significant costs and long-term implications. Pharmacy benefit managers can help by reviewing prescriptions, identifying whether generic or clinically appropriate alternatives are available, and checking for potential contraindications. An excess workers’ compensation carrier may also have specialized resources to help review an injured worker’s treatment plan. Where appropriate, an excess carrier can help evaluate medical necessity, claim exposure, and cost management considerations while supporting appropriate care.

Building Trust Through Clear Communication

Employees in roles that involve high physical risk or demand may be skeptical of the workers’ compensation system, making clear and consistent communication an important component of building trust. This starts by setting expectations early so the injured worker and their family or support structure understand each person’s role in the process. They should clearly understand what benefits are available to them and who to contact for their needs. Maintaining a regular cadence of updates may help the injured worker feel supported. Any lack of transparency or rushed communication can leave an employee confused, potentially creating distrust and making the process feel more adversarial.

Planning for Long-Term Outcomes

A resolution can be difficult in cancer, heart, and lung claims because an injured worker may be uncertain of their future medical needs. Their support structure and colleagues may also discourage settlement based on personal experiences or perceived outcomes. Once a claim is accepted, settlement may become more challenging, making early investigation, compensability analysis, and strategy especially important. Life care planning and long-term cost projections can act as tools to better understand potential future treatment, disability exposure, and ongoing support needs. Claims teams should continue exploring resolution options where appropriate while recognizing that there may not be a standard path to closure.

While no single professional can manage these claims alone, an engaged, coordinated team can better support appropriate care, help control costs, and can help to improve the likelihood of a manageable long-term outcome.