‘Total system breakdown’: California firefighters with PTSD face a workers’ comp nightmare

Todd Nelson could feel it coming on. And he began to run. He was going dark again, retreating to a place where he would curl into a fetal position with his thumb in his mouth, watching from behind closed eyes as his personal reel of horror unspooled. Sights and sounds from three decades of firefighting cued up — shrieks from behind an impenetrable wall of flame, limbs severed in car accidents and the eyes of the terrified and the dead he was meant to save.

Nelson was running on the Foresthill Bridge, the highest in California, fleeing cops and firefighters after his wife reported that he was suicidal. He hurdled a concrete barrier and straddled the railing of the bridge in the Sierra Nevada foothills, staring down at a large rock 730 feet below. As the rescuers closed in, Nelson leaned precariously over the chasm. His strategy — making the fatal plunge appear accidental, allowing his family to collect his life insurance.

It was not Nelson’s first suicide attempt — the former Cal Fire captain had tried to take his life many times before. But that 2021 ordeal, which led to an involuntary 72-hour psychiatric hold, something in him shifted. He was ready to admit that he had a problem and seek medical help.

The incident began the firefighter’s arduous, years-long journey toward wellness, threaded through a bureaucratic labyrinth strewn with more obstacles than he’d ever encountered on a California wildfire: finding qualified medical help, battling an insurance company to pay for it and navigating the tangled morass of California’s workers’ comp. All without going broke or returning to his dark place.

No one tracks how many of Cal Fire’s 12,000 firefighters and other employees suffer from mental health problems, but department leaders say post traumatic stress disorder and suicidal thoughts have become a silent epidemic at the agency responsible for fighting California’s increasingly erratic and destructive wildfires. In an online survey of wildland firefighters nationwide, about a third reported considering suicide and nearly 40% said they had colleagues who had committed suicide; many also reported depression and anxiety.

California’s workers’ comp — which is supposed to help people get medical treatment for workplace illnesses and injuries — can be a nightmare for firefighters and other first responders with PTSD.

Claims filed by firefighters and law enforcement officers are more likely to involve PTSD than claims by the average worker in California — and they have been denied more often than claims for other medical conditions, according to the research institute RAND.

From 2008 to 2019 in California, workers’ comp officials denied PTSD claims filed by firefighters and other first responders at more than twice the rate of their other work-related conditions, such as back injuries and pneumonia, RAND reported. About a quarter of firefighters’ 1,000 PTSD claims were denied, a higher rate than for PTSD claims from other California workers.

“It’s a fail-first system. You have to get a broken leg to show you are in need of support. With mental illness, we are constantly having to prove to everybody why we were ill. You have to get to the point of suicide,” said Jessica Cruz, the California chief executive officer of the National Alliance on Mental Illness.

Jennifer Alexander, Nelson’s therapist, said patients in acute crisis simply don’t have the mental capacity to ride herd on stubborn workers’ comp claims. Alexander said she was once on hold for more than six hours with Cal Fire’s mental health provider attempting to get one of her bills paid, and she has waited years to get paid for treating firefighters.  

“People give up. It’s a battle… They are not fully functional,” said Alexander, who for 21 years has specialized in treating first responders with trauma and PTSD and has spent an estimated 25,000 hours treating them. “You are not talking about healthy individuals who can sit on the phone for hours.”

Cal Fire firefighters and other workers also have trouble finding qualified therapists, especially outside major cities in rural areas, where many are based. In 2021, less than half of people with a mental illness in the U.S. were able to access timely care. Therapists are reluctant to take workers’ comp, or sometimes any type of insurance. because they often have to wait months or years to be reimbursed.

Therapist Jennifer Alexander listens to Nelson during a treatment session. She called workers’ comp a “total system breakdown.”

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Cristian Gonzalez

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CalMatters

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Michael Dworsky, a senior economist at the research institute RAND and one of the study’s project leaders, called workers’ comp “challenging and bureaucratic.”

“Even if the claim is accepted, there can be disputes about the medical necessity of individual bills. Just because your claim is accepted, doesn’t mean you are done fighting with the insurance company,” he said.

A presumption of pain but still a tangled web

Employers in California must provide workers’ comp insurance that will pay for medical costs when a worker is injured on the job. But in reality, workers’ comp, which serves 16 million Californians, can be ungainly, confusing and, sometimes, no help at all. The system, administered by the state Department of Industrial Relations, is massive: In 2022 almost 750,000 workers’ comp claims were filed statewide.

When a firefighter requests coverage for medical treatment, insurance adjusters review the case to determine if it’s medically necessary. If the claim is denied, delayed or modified, a patient may request an independent medical review by so-called “ghost doctors” who review the case.

Systemwide in California, patients who appeal their denied workers’ comp claims, don’t fare well: Last year 3,238 appeals for mental health claims were filed, but workers’ comp officials rejected three-quarters of them, about the same as the 10-year average, according to data from the Department of Industrial Relations requested by CalMatters. (Agency officials said they could not provide data on claims from first responders.)

For decades, the California Legislature has wrestled with how to fix workers’ comp — in one year alone lawmakers proposed nearly two dozen bills.

In 2020 lawmakers took a major step, adding a legal shortcut or “presumption” to the state labor code, stipulating that firefighters and other first responders are considered at high risk for PTSD in the course of doing their job.

That means first responders no longer carry the burden of proving their illness is work-related. However, a claims adjuster can still question the diagnosis or assert that the trauma was caused by other factors, such as military service or family events. A law enacted last year extended the presumption to 2029.