Disability Presumptions--Task Force Report

TASK FORCE ON PUBLIC EMPLOYEE DISABILITY PRESUMPTIONS

Report to The Governor, Legislature, and

Chief Financial Officer January l ,20 12

Task Force on Public Employee Disability Presumptions

TABLE OF CONTENTS

Executive Summary ................................................................................................................................................ 3

...................................................................................................................................................... I . Introduction 8

A . Authority and Scope of Review .................................................................................................................... 8

B . Meetings and Membership ........................................................................................................................... 8

I1 . Data collected related to the operations of the statutory disability presumptions and fiscal impact on public ......................................................................................................................................................... employers 9

A . State of Florida Data ................................................................................................................................. 10

B . Municipal Government Data ...................................................................................................................... 12

C . CountyISheriff Department Data ............................................................................................................... 13

D . State Retirement System Data ................................................................................................................ 14

I11 . State Comparisons ......................................................................................................................................... 15

A . Presumption Laws and Qualifying Provisions ........................................................................................... 15 . . B . Covered Cond~tlons ................................................................................................................................... 16

IV . Find'mgs and Recommendations .................................................................................................................. 18

A . Evidentiary Standards and Burden of Proof for Overcoming Disability Presumption ............................... 18

1 . Legal Issues Which Present Challenges to the Prosecution of Presumption Claims &Proposed Statutory Changes ...................................................................................................................................................... 19

2 . Legal Issues Which Present Challenges to the Defense of Presumption Claims & Proposed Statutory Changes ...................................................................................................................................................... 21

B . General Application of Presumption Laws and Mitigation of Claim Costs (Not involving Evidentiary Standards or Burden of Proof Issues) ................................................................................................... 24

V . Signature Page ......................................................................................................................................... 28

Attachments ......................................................................................................................................................... 29

Final Report January 1. 2012

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Executive Summary The Task Force on Public Employee Disability Presumptions was established pursuant to Chapter 201 1-216, Laws of Florida, to review data related to the operation and fiscal impact of statutory disability presumptions, review how other states handle disability presumptions, review evidentiary standards and burdens of proof for overcoming statutory disability presumptions and consider risk factors and epidemiological data, and provide its findings and proposals for changes to existing statutory disability presumptions.

The Task Force found generally that for all governmental entities represented, the incurred average cost per workers' compensation claim is lower than the incurred average cost per disability presumption claim. In addition, for all governmental entities, the percent of incurred cost for presumption claims relative to all workers' compensation costs is higher than the percent of the number of presumption claims when compared to all workers' compensation claims.

Among the 50 states, 35 states have some form of disability presumption law. These laws vary in coverage to include firefighters, emergency medical technicians, law enforcement officers, and correctional officers. In 26 states, including Florida, the presumption arises only if the claimant passed a pre-employment physical examination which did not reveal the presence of the disease or condition for which benefits are claimed. In 20 states, not including Florida, presumption compensability only arises after a first responder has served in the covered occupation for a specified number of years. In 32 states, the law provides for a rebuttable, rather than an absolute, presumption.

As could be expected given the composition of the Task Force members, no consensus was reached on all of the findings and recommendations made by the Task Force, with the exception that members agreed a wellness program could help reduce group health claims and workers' compensation claims generally, with the consequence of also reducing disability presumption claims.

SUMMAFtY OF RECOMMENDATIONS

Recommendation 1: Because claimants must prove their case in non-presumptive claims by clear and convincing evidence, the evidentiary standard in rebutting a presumptive claim should be clear and convincing.

Supported by Task Force Members: Michael Clelland, Gany Mitchell, Jim Tolley

Recommendation 2: "Disability" should be defined as: the event of an employee's becoming actually incapacitated, partially or totally, because of an occupational disease, from performing his work in the last occupation in which injuriously exposed to the hazards of such disease, OR an employee's actual impairment pursuant to the 1996 Florida Uniform Impairment Rating Schedule or other impairment guide incorporated into the Workers' Compensation Act at the time of the disablement.


Final Report January 1,2012

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Recommendation 3: What amounts to evidence of the conditions of heart disease or hypertension is a medical question and should be left to medical doctors testifying in a particular case.


Recommendation 4: Preclude an employee that is smoking tobacco products from being able to utilize the presumption as it is a significant risk factor for both hypertension and heart disease.

Supported by Task Force Members: Michael Clelland, Gany Mitchell, Peter O'Bryan, Jim Tolley

Recommendation 5: An individual must be employed with the current employer for at least 10 years to be eligible for a disability presumption.

Supported by Task Force Members: Peter O'Bryan, RJ. Castellanos, Alan Kalinoski, Timothy McCausland

Recommendation 6: An individual must be under 37 years old to be eligible for a disability presumption.

Supported by Task Force Members: Peter O'Bryan, RJ. Castellanos, Alan Kalinoski, , Timothy McCausland, Tommy Wright

Recommendation 7: So that the requirement to successfully pass a physical examination is uniform, $175.231, F.S., for firefighters, and 5185.34, F.S., for municipal police, should be amended to conform with 5 112.18(1) (a), F.S.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Alan Kalinoski, Timothy McCausland, Garry Mitchell

Recommendafion 8: Any evidence of elevated blood pressure (defined as systolic pressure of 130 or higher or diastolic pressure of 80 or higher), as well as any EKG or other cardiac, coronary artery or heart abnormality, or positive tuberculosis test identified on the physical examination performed upon the employee entering into service with the employer against whom the disability presumption is being sought shall be considered evidence of hypertension, heart disease andlor tuberculosis as a basis for denying application of a disability presumption.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Alan Kalinoski, Timothy McCausland, Tommy Wright

Recommendation 9: Disability presumptions for heart disease and hypertension pursuant to 51 12.18, F.S., shall be limited to coronary artery disease and arterial or cardiovascular hypertension resulting in both disability and permanent impairment.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Alan Kalinoski, Timothy McCausland

Recommendation 10: To be eligible to receive benefits for any disability presumption, a person would be required to be incapacitated from performing their work for a minimum of 14 contiguous days as a result of treatment for a covered condition.


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Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Alan Kalioski, Timothy McCausland, Gany Mitchell

Recommendation 11: Risk factors and epidemiological data relating to non-work-related conditions unique to an individual, such as blood cholesterol, body mass index, history of alcohol use, family history of hypertension andlor heart disease, diabetes, and other medical conditions or behaviors that are associated with the disease or condition subject to a disability presumption shall be considered as a basis for the denial or rebuttal of the application of a disability presumption.

Supported by Task Force Members: Peter O'Bryan, RJ. Castellanos, Alan Kalinoski, Timothy McCausland, Tommy Wright

Recommendation 12: An individual shall forfeit a disability presumption if the individual has been or is a user oftobacco products.

Supported by Task Force Members: Peter O'Bryan, RJ. Castellanos, Alan Kalinoski, Timothy McCausland, Gany Mitchell

Recommendation 13: A disability presumption shall be overcome by a preponderance of the evidence.


Recommendation 14: The provisions of section 112.18(1)@), Florida Statutes, relating to a workers' compensation claim and d e p m e from a prescribed course of treatment shall apply to firefighters (these provisions are already applicable to a law enforcement officer, correctional officer, or correctional probation officer).

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Alan Kalinoski , Timothy McCausland, Tommy Wright

Recommendation 15: The Florida Uniform Permanent Impairment Rating Schedule shall not apply to any claim brought pursuant to 112.18, Florida Statutes. Pemmnent impairment for any claim brought pursuant to 112.18 shall be determined pursuant to specific impairment guidelines established to be solely applicable to claims brought pursuant to 112.18, Florida Statutes.


Recommendation 16: The date of accident for an individual bringing any claim for any disability presumption shall be limited to the date that the employee first incurs disability as a result of treatment for a covered condition. Any subsequent period(s) of disability would not result in a new date of accident, but would be referred to the original date of accident.



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Recommendation 17: Amend §633.34(5), and §943.13(6), F.S., to provide that a medical examination for any person applying for employment as a firefighter may include, but not be limited to history and profile review and analysis of risk factors and epidemiological data related to non-work related conditions such as tobacco products use,body mass index, high cholestero1;alcohol use, family history of heart disease or hypertension, and- provisions of the National Fire Protection Association Standard 1582.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Alan Kalinoski , Timothy McCausland, Gany Mitchell

Recommendation 18: Add a new provision as §633.34(7), F.S., requiring that employees hired after July 1, 20 12, must continue to be a non-user of tobacco products with the employing entity during their employment as a firefighter.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Alan Kalinoski , Timothy McCausland, Garry Mitchell, James Tolley

Recommendation 19: A psychological test should be used as a pre-employment tool to assess fitness for duty. Psychological evaluation tools already exist; however, a psychologist is required to administer such a test and interpret the results. Criteria should be developed to determine agency actions based upon test results.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos , Timothy McCausland, Gany Mitchell

Recommendation 20: Professional mental health counseling services should be available to employees after a traumatic event, and as needed as a preventive measure. Counseling services would be contingent on budgetary considerations and should apply as an on-going resource to employees covered under the presumption law to reduce risk for hypertension and heart disease problems resulting from negative impacts to mental health.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos , Timothy McCausland, Gany Mitchell

Recommendation 21: Minimum fitness standards as to bodv mass ratio. liftine streneth. cardiovascular - endurance, alcohol consumption, and tobacco product use should be required to be established by all governmental employers for all employees benefitting from the disability presumption. Fitness for duty should be determined before an employee is selected and hired, and should be incorporated as a routine part of continuing employment.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos , Timothy McCausland, Garry Mitchell, Tommy Wright

Recommendation 22: Minimum hiring standards for fitness should be developed and provided to the physicians assisting with the preemployment evaluation.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos , Timothy McCausland, Gany Mitchell, Tommy Wright


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Recommendation 23: If an employee requires clearance because of information reported on a pre-employment form, agencies should obtain detailed physician follow-up evaluations and recommendations and these should be maintained in the employment records. Storage and access to the employment records should be uniform throughout the agencies.

Supported by Task Force Members; Peter O'Bryan, RJ. Castellanos, Gany Mitchell, Tommy Wright

Recommendation 24: Afier initial employment, employees' fitness should continue to be monitored so that issues can be identified and requirements for ongoing employment can be developed. The workday should include time for stress-reducing or health-related activities.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Gany Mitchell

Recommendation 25: Health and wellness promotion should be incorporated by design into agency operations, and health and wellness information should be available and accessible to employees at work and away from work. Wellness programs should be instituted by agencies employing officers that are covered by the presumption claim statutes.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Michael Clelland , Timothy McCausland, Gany Mitchell, Jim Tolley

Recommendations 26: A website and/or newsletter should be developed or co-opted as part of a wellness program to disseminate health information to employees on a regular basis.


Recommendation 27: Personal contact and interactive support systems among colleagues, such as a mentoring program, should be developed as part of a wellness program to provide employees a vehicle to address traumatic events and release anxiety and frustration in a mutually supportive environment.

Supported by Task Force Members: Peter O'Bryan, RJ. Castellanos, Michael Clelland , Timothy McCausland, Gany Mitchell, Jim Tolley

Recommendation 28: That the Legislature provide funding for an actuarial special study to determine the funding costs of presumption claims for in-line-of-duty disability presumptions

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Timothy McCausland, Gany Mitchell, Tommy Wright

Recommendation 29: The presumption should not be available as a worker's compensation provision if an employee is covered by an employer-sponsored health insurance program.

Supported by Task Force Members: Alan Kalinoski, Timothy McCausland, Tommy Wright


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Report of the Task Force on Public Employee Disability Presumptions

A. Authority and Scope of Review

Pursuant to Chapter 201 1-216, Laws of Florida, the Task Force on Public Employee Disability Presumptions was created for the purpose of developing findings and issuing recommendations on the statutory disability presumptions related to certain public employees and to certain Florida Retirement System retirees. The task force is composed of eight members, including three members appointed by the President of the Senate, three members appointed by the Speaker of the House, a member appointed by the Governor from the Department of Management Services, Florida Retirement System, and a member appointed by the Chief Financial Officer from the Department of Financial Services. The task force is required to address data related to the operation and fiscal impact of statutory disability presumptions, how other states handle disability presumptions and its fiscal impacts, proposals for changes to existing statutory disability presumptions, evidentiary standards and burdens of proof for overcoming statutory disability presumptions, and consideration of risk factors and epidemiological data. The task force is required to produce a final report by January 1,2012, and will dissolve after the production of the final report. A complete text of the law establishing the Task Force may be found in the attachments to this report (Attachment 1).

Note: Despite the legislative mandate under Chapter 201 1-216, Laws of Florida, " ... a member of a pension plan under Chapter 185, Florida Statutes" be a part of the Task Force, no such member was appoint&. consequently, no input from this protected class was received by the Task Force.

B. Meetings and Membership

The task force met September 3 0 ~ , October 17", November 22nd, and December 12" (Attachment 2). Task force members presented data and information at the meetings; received data and took clarifying testimony regarding data from the Florida League of Cities, the Florida Sheriffs Association, and the Division of Risk Management, Department of Financial Services; discussed their findings and recommendations; and developed a report.

Task force members were selected based upon their expertise and involvement with statutory disability presumptions. Membership included representatives from the firefighter community, legal community, local government, state government, and retirement system. Detailed information about each member is provided below.


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President of Michael Cleliand 407-629-8300 Attorney representing Senate [email protected] injured workers I

Peter O'Bryan

Speaker of House of

Representatives

James Tolley

772-226-1440 p ~ b ~ a n @ i r ~ a ~ v . ~ ~ r n

County Commissioner. Indian River County

850-224-7333 tollev@minds~rina.com

Alan Kalinoski

Garry Mitchell 407-965-5063 Firefighter Engineer, City of [email protected] Winter Park

Governmental Relations Director, Florida

Professional Firefighters

Timothy McCausland

Governor L

407-422-431 0 [email protected]

Chief Financial Officer

Attorney representing governmental entities

863-834-601 0 [email protected]

Tommy Wright

City Attorney, City of Lakeland

R. J. Castellanos

Assistant General Counsel, Department of

Management Services. Florida Retirement System

Director. Division of Risk Management

The Task Force found generally for a l l governmental entities represented that the incurred average cost per workers' compensation claim i s lower than the incurred average cost per disabilitv oresumotion claim. In addition; for a l l governmental entities, the percent o f incurred &st for presuKption ciainis relative to al l workers' compensation costs is higher than the percent of the n u m p m p t i o n


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claims when compared to all workers' compensation claims. The data presented below for governmental agencies includes benefit costs and legal costs.

A. State of Florida Data

The following data was obtained from the Division of Risk Management in the Department of Financial Services, which administers the workers' compensation claims for most state government agencies.

The impact of presumption claims on Florida state agencies is shown below. Over a 12 year period from FY 1999-2000 to FY 2010-201 1, the actual paid cost of presumption claims has increased by approximately 330 times from $24,493 to $8.1 million. This increase in large part was due to 2003 changes in the law that added correctional officers to eligible employees. Detailed data tables are attached (Attachment 3). All data presented reflects claim payments made in a fiscal year for all claims regardless of the date of accident, so that payments on prior year claims as well as current year claims are included. The chart below shows the steady increase of claim costs with a spike in FY 2006-2007, which can be explained by the industry standard of 3 years for a claim to mature and increasing correctional officer awareness and utilization of disability presumptions.

State of Florida Presumption Payments by Fiscal Year Transaction Date

Workers' compensation costs have increased by approximately 1.54 times from $76.6 million in FY 1999-2000 to $1 18 million in FY 2010-201 1. The chart below shows workers' compensation costs (including legal costs) have remained relatively flat with increases and decreases in a range of $20 million for 9 years, then an upward trend starting in FY 2007-2008.

Final Report January 1.2012

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State of Florida Workers' Compensation Payments by Fiscal Year Transaction Date

3,864 $125,000,000

$100,000,000

$75,000,000

$50,000,000

$25,000,000

$0

Over a 12 year period, the average disability presumption claims cost was $1 1,153 as compared to $4,115 for the average workers' compensation claims cost. For 10 of the 12 years, the average disability presumption claim cost has been approximately double or more the average workers' compensation claim cost. Because presumption driven benefits are more expensive than non presumption workers' compensation benefits, State agencies and other public employers typically assert their defenses vigorously to avoid paying those costs. This is a contributing factor to the higher cost of presumption claims. Average disability presumption claim costs are also generally higher due to more complex litigation and resulting attorney fees, higher medical costs and higher lost wages (Attachment 3). See chart below for a cost comparison.

State of Florida Average Payment Comparison

$18,000

$16,000

$14,000

$12.000 Average WC

$10,000 Payment

$8,000

$6,000 Average

$4,000 Presumption

$2,000 Payment

$0

I FY FY FY FY FY FY FY FY FY Fy FY FY All 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Years 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011


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B. Municipal Government Data

The data provided below from the Florida Municipal Insurance Trust (FMIT) is representative of the loss experience of municipalities resulting from disability presumption claims. This data is presented on an incurred cost basis, which includes paid costs and reserves estimated to be required for future claim payments. The data covers FMIT member cities, which number approximately 240. There are approximately 400 municipalities in Florida. The larger municipalities of one hundred thousand or more in population are self-inswed or participate in private insurance. The Florida League of Cities official providing the information estimated that the data covered about 10% to 15 % of the total number of all municipal officers entitled to the statutory presumptions.

The data in the following two charts reflect that presumption costs as compared to overall workers' compensation costs are higher than presumption frequency as compared to overall workers' compensation frequency. In FY 2008-2009 and FY 2009-2010, presumption costs were more than half of overall workers' compensation costs, while 76 and 73 presumption claims were filed respectively as compared to 899 and 690 total workers' compensation claims (Attachment 4).

The disproportionate difference is due in part to a higher average cost of presumption claims. The average cost for a presumption claim over the years reviewed was $35,917 as compared to the average cost of $8,775 for a workers' compensation claim (Attachment 4).

According to the Florida League of Cities representative, the reason for the spike in presumption costs in FY 2008-2009 and FY 2009-2010 was due to an increase in new members participating in the FMIT.

Florida Municipal Insurance Trust Municipal FirefPolice Workers' Compensation-Presumption Incurred Cost Comparison

$16,000,000

$14,000,000 rn Total WC 6 $12,000,000 '0

Incurred IY :: $10,000,000 Liability

a E $8,000,000 - -

$6,000,000 .Total c Presumption

$4,000,000 Incurred 5 $2,000,000 Liability

$0


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Florida Municipal Insurance Trust Municipal Fire/Poiice Workers' Compensation-Presumption

Frequency Comparison

W F Y W W F Y M W W F Y F Y F Y F Y W F Y 97-98 98-99 99-00 00-01 01-02 02-03 03-04 04-05 05-06 06-07 07-08 08-09 09-10 10-11

Fiscal Year Runs From October 1st Through September 30th.

Number of FirelPolice WC Claims

Number of Disability Presumption Claims

C. County/Sheriff Department Data

Florida sheriffs' data shown below is for sheriffs' offices that are members of the Florida Sheriffs' Workers' Compensation Self-Insurance Fund. This is the largest self insurance fund for sheriffs, and includes 28 sheriffs representing small and medium sized counties. This data is also presented on an incurred basis. Presumption claims have ranged from a low of $852,573 in FY 2010-201 1 to a high of $6,366,716 in FY 2006-2007 for a total of $31,934,617 for all years reviewed (Attachment 5).

Fiscal Year of Claims 1 Final Report January 1,2012

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Florida Sheriffs' presumption claims costs have been high over presumption claims frequency when compared to overall workers' compensation claims costs and frequency. The chart below shows presumption claims account for 2.86%' of all workers' compensation claims, while presumption claims costs account for 32.64% of all workers' compensation claims costs. This representation can be explained in part by the average presumption claim cost of $62,740 as compared to the average workers' compensation claim cost of $5,487 (Attachment 5). However, it should be noted that a greater percentage of a sheriffs department workforce consists of law enforcement officers than is found in other governmental agencies, and this data does not include claims data from other county agencies.

Presumption %of WC Claims Presumption % of WC Incurred Costs

I

Claims and Costs Comparison

Florida Sheriffs' Fund Comparison Presumption Claims and Costs as % of Workers' Compensation Claims and Costs

FY 2001-2002 through FY 2010-2011 ,

D. State Retirement System Data

The Florida Retirement System (FRS), as it currently exists, was created in 1970. The disability presumptions that apply directly to the FRS are found in Sections 112.18 and 112.181, Florida Statutes. The FRS covers approximately 640,000 active public employees in Florida. Service retirement benefits are calculated by multiplying the number of years of service in each class times the accrual value for each class (1.6% for regular class employees, 3% for special risk members, including police, firefighters, and corrections officers), and multiplying that product by the average final compensation

Disabilitv retirement benefits are generally calculated in the same manner as are normal retirement benefits,-except that minimum regular disability benefits are set at 25% of AFC. Mmimum in-line-of: dutv disabilitv benefits are set at 42% of AFC for remlar class members, and 65% of AFC for special risk class members, including police, firefighters an2 correctional officers. To date, there have deen no


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Task Force on Public Employee Disability Presumptions 8 experience studies to determine the cost of the presumptions for FRS members. Disability retirement benefits are not subject to an early retirement reduction, and in-line-of-duty disability benefits are tax exempt up to the minimum levels.

For the fiscal years 2008-09 through 2010-1 1, there were 76 claims for in-line-of-duty presumptions. Sixty eight of those claims were for the heart presumption, ofwhich 55 were approved. Sixteen claims were for the hypertension presumption, of which 14 were approved. One claim each was approved for the tuberculosis and hepatitis presumptions, respectively.

There are approximately 35 1 local retirement plans in Florida covering firefighters or police officers that are subject to a disability presumption for these employees. Of the local system actuaries polled, the response was consistent that when determining funding needs, the assumption used is that all disability retirement awards will be in-line-of-duty claims. No cost experience studies were located for local plans.

A. Presumption Laws and Qualifying Provisions

In response to the Legislature's directive, the Task Force compiled extensive data related to how other states have implemented presumption provisions and analyzed how they compare in regard to what type benefits are offered, the occupation of employees covered, the nature of diseases or conditions that are deemed to be job related by operation of presumption provisions, and what limitations or qualifications are required before the presumption applies. Not surprisingly, the schemes across the country vary widely in these areas because very few states statutory language is identical. Because of this, specific state by state comparisons are nearly impossible. However, although there may be specific variations when analyzed in detail, generalized comparisons can be illustrative.

The data indicates that certain states can be categorized as having broad, expansive provisions characterized by more work groups entitled, diseases covered being numerous and broadly defined, and having defenses to employers to disprove job characteristic causation limited. Examples with more liberal schemes would be states like Florida, Missouri, andNew Jersey, who offer the presumption to all state and local police, fire, EMTIparamedic, and in Florida's case, correctional officers, include broad, expansive definitions of covered diseases like "heart disease" and "lung disease," and consider the presumption not rebuttable once it is established, as is the case in Alabama. States with more restrictive schemes are characterized by making the presumption applicable to fire only (Like Texas or Washington) and then only when associated with a specific cardiac event like heart attack, or myocardial infarction, or a specific lung disease, and then only following active exposure in the line of duty. In some of those states, employees must have been in the occupation for a number of years, and may be disqualified by tobacco use. Standardized cost experience from the various states is not available or if it is, it is likely unreliable for comparison purposes.


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The National Council on Compensation Insurance, Inc. (NCCI) has compiled data relative to the various state statutory Presumption Laws that qualify first responders for Worker's Compensation benefits. Additional research by the Task Force supplemented this data to include disability retirement benefits. The following is a summary of the relevant data outlining the manner in which other states handle disability presumptions. It should be noted that this analysis represents a snapshot in time, since all states appear to consider legislation to implement or modify schemes regularly.

General Provisions: Only seven states, Arkansas, Delaware, Kentucky, Mississippi, Montana, North Carolina, and Wyoming have no statutory Presumption laws. Connecticut has made the provision applicable to employees hired before 1996. Nebraska and several states restrict the application of presumption laws to disability retirement only. Thirty-five states have some form of statutory Presumption Law applicable to firefighters, law enforcement officers and emergency medical technicians which could result in certain diseases andlor other conditions to be presumed to be cornpensable (work-related) under those states' workers' compensation laws. In twenty-six states, including Florida, the Presumption Law is applicable only if the employee (claimant) had a pre- employment (time-of-hire) physical examination which did not reveal the presence of the disease or condition for which benefits are claimed. Twenty-five states require that a first responder serve in their employment capacity for a specified number of years (the range is from 2 to 15 years) before its Presumption Laws become applicable. Florida currently has no minimum number of years of service required to qualify for its Presumption laws. South Carolina's law provides that its Presumption Law is available only to firefighters and law enforcement officers who are under 37 years of age at the time of the filing of their claim (See Section 42-11-30 (a), South Carolina Statutes), whereas some states require claims within a certain time period or contemporaneous with on duty activity. Thirty-two states, including Florida (See section 112.18(1); 112.181(2), Florida Statutes), provide that i ts~resum~tion Law is rebuttable where some establish the presumption conclusively. Some states allow the Presumption to be overcome by a preponderance of evidence to show the usd of tobacco products, physical fitness and weight criteria, life style, hereditary factors, certain risk factors, and exposure from other employment activities, where in others, the Presumption is conclusive or l i e in Florida, must be overcome by "clear and convincing" evidence. The State of Oregon provides that its Presumption can be overcome by clear and convincing medical evidence that the cause of the condition or impairment is unrelated to a claimant's employment (Section 656.802 (4), Oregon Statutes).

B. Covered Conditions for Workers' Compensation Coverage.

m: Twenty-two states provide a Presumption Law for certain types of cancer for firefighters. Four states provide a Presumption Law for certain types of cancer to law enforcement officers. Four states provie a ~ r e s u m ~ t i o n i a w for certain types %cancer for emergency medical technicians. Florida does not have a Presumotion Law for firefighters, law enforcement officers or emergency - - - medical technicians for cancer.


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Heart Diseasemeart Attack: Thirty-one states provide a Presumption Law for heart disease and/or heart attack to fuefighters. Sixteen states provide a Presumption Law for heart diseaselheart attack for law enforcement officers. Seven states provide a Presumption Law for heart diseaselheart attack for emergency medical technicians. Florida provides a Presumption Law for heart disease for firefighters and law enforcement officers.

Hvoertension: Ten states provide a Presumption Law for hypertension for firefighters. Five states provide a Presumption Law for hypertension for law enforcement officers. Three states provide a Presumption Law for hypertension for emergency medical technicians. Florida provides a Presumption Law for hypertension for firefighters and law enforcement officers.

Lung/Res~iratory: Twenty-eight states provide a Presumption Law for certain lunghespiratory conditions for firefighters. Eight states provide a Presumption Law for certain lunglrespiratory conditions for law enforcement officers. Four states provide a Presumption Law for certain lunghespiratory conditions for emergency medical technicians. Florida does not have a Presumption Law applicable for lung/respiratory conditions for firefighters, police officers or emergency medical technicians.

Vascular Conditions: Eight states have a Presumption Law for certain vascular conditions for fuefighters. Four states have a Presumption Law for certain vascular conditions for law enforcement officers. Three states have a Presumption Law for certain vascular conditions for emergency medical technicians. Florida does not have a Presumption Law applicable to fuefighters, law enforcement officers or emergency medical technicians for vascular conditions other than heart disease.

Other Svecified Conditions: Twenty-two states have a Presumption Law for other specified conditions. Florida provides a limited Presumption Law for hepatitis, meningitis and tuberculosis for firefighters, law enforcement officers and emergency medical technicians (See Section 112.181, Florida Statutes).

Tobacco Use: Eight states have limitations on tobacco use ranging from an absolute prohibition of any history of tobacco use to only showing no use two years prior to filing a claim.

In conclusion, the task force finds that presumption laws vary widely across the country. Firefighters are more often covered when compared to other worker groups. The presumptions are only available to law enforcement and firefighter work groups, and other work groups that also encounter hazardous conditions in the workplace are not included. The covered diseases often apply to all work groups even though job related environment and conditions vary greatly among the covered work groups.

The following chart shows a breakout of states with laws, qualifying provisions and covered conditions. For more details, see attachment (Attachment 6).


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States with Presumption Laws, Qualifying Provisions and Covered Conditions

A. Evidentiary Standards and Burden of Proof for Overcoming Disability Presumption

The presumption statutes (5175.231, F.S., 5185.34, F.S., and 5 112.18 F.S.) are all worded the same as to the required evidence. All require "competent evidence" to overcome the presumption. While the phrase "competent evidence" generally refers to any evidence that is admissible to prove a fact, i.e. a preponderance of evidence, the courts have often construed this provision to require the higher standard of proof of "clear and convincing" evidence to overcome the presumption. A successful defense to a presumption claim requires testimony by medical experts, with the associated costs.

The presumptions apply both to worker's compensation henefits as well as to retirement benefits. Unlike worker's compensation henefits, however, a claimant need only demonstrate in line of duty causation and total and permanent disability fkom all employment by a preponderance of the evidence to receive an award of benefits under the retirement system.

The Task Force received and reviewed various reports on studies and other literature regarding the relationship of injury causation to a public worker's occupational environment. There was considerable debate among Task Force members as to whether there exists a causative link between occupational activities and heart disease. The Task Force recommends that the Legislature explore this issue further, with a panel of neutral medical experts to review the published literature.


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Generally, the Task Force finds that the recent legislative enactment of House Bill 2176 (Chapter 2010- 275, Laws of Florida), amending the presumvtion law, $1 12.18, F.S., provided substantial clarification - . regarding the future parameters as to when h e presun$ion applies (Attachment 8). This legislation disallows the presumption if the officer departs in a material fashion from the prescribed medical course of treatment for heart disease, tuberculosis or hypertension, and limits claims to those made within 180 days of leaving employment. This legislation should be amended to include Firefighters, especially if a public entity adopts a "Wellness Initiative".

However, given the composition of the Task Force, there are differing views held by Task Force members about the changes that should be recommended regarding evidentiary standards and burdens of proof involving the disability presumptions. Therefore, the views of the injured worker representatives on the task force and those of the governmental entity representatives are presented separately below, through a presentation of issues and recommendations prepared by attorney members of the Task Force that represent injured workers and governmental entities.

1. Legal Issues Which Present Challenges to the Prosecution of Presumption Claims & Proposed Statutory Changes (Prepared by task force member Attorney Michael Clelland, who represents injured workers).

[a) Evidentiarv Standards in Rebutting the Presumvtion- $1 12.18(l)(a), Florida Statutes (F.S.) reads, in pertinent part: Any condition or impairment of health of any Florida state, municipal, county, port authority, special tax district, or fire control district firefighter or any law enforcement officer, correctional'officer, or correctional probation officer as defined in 5 943.10(1), (2), or (3), F.S., caused by tuberculosis, heart disease, or hypertension resulting in total or partial disability or death shall be presumed to have been accidental and to have been suffered in the line of duty unless the contrary be shown by competent evidence. (emphasis added)

However, in Caldwell v. Division of Retirement, the Florida Supreme Court addressed this issue as follows:

The statutory presumption is the expression of a public policy which does not vanish when the opposing party submits evidence. Where the evidence is conflicting, the quantum ofproof is balanced and the presumption should prevail. This does not foreclose the employer from overcoming the presumption. However, if there is evidence supporting the presumption the employer can overcome the presumption only by clear and convincing evidence. In the absence of cogent proof to the contrary the public policy in favor ofjob relatedness must be given effect. (emphasis added)

In Caldwell, the Court considered a pension case, but subsequent Florida case law makes such law applicable to workers' compensation claims as well.

Final Report Page 19 January 1,2012


Recommendation I : The conditions under §112.18(1) (a), F.S. are occupational diseases. In any other occupational disease claims (not covered by a presumption), the claimant has the burden to prove causation by clear and convincing evidence. See $440.151, F.S. Therefore, because claimants must prove their case in non-presumptive claims by clear and convincing evidence, the evidentiary standard in rebutting a presumptive claim should be the same-clear-and-convincing.


[b) Disability-despite extensive appellate review, what amounts to sufficient disability remains unclear.

Recommendation 2: "Disability" should be defined as: the event of an employee's becoming actually incapacitated, partially or totally, because of an occupational disease, from performing his work in the last occupation in which injuriously exposed to the hazards of such disease, OR an employee's actual impairment pursuant to the 1996 Florida Uniform Impairment Rating Schedule or other impairment guide incorporated into the Workers' Compensation Act at the time of the disablement.


(c) Pre-Em~lovment Phvsical (PEP)- Evidence of the condition claimed (heart disease, hypertension, tuberculosis) must not be present on the PEP.

Recommendation 3: A single, isolated, high blood pressure reading is not evidence of the "condition" of hypertension. A single, isolated, high blood pressure reading may be suggestive of other conditions such as White Coat Syndrome, which is not the condition "hypertension." What amounts to evidence of the conditions of heart disease or hypertension is a medical question and should be left to medical doctors testifying in a particular case.


(d) Risk Factor* The Appellate Court has left it in the hands of the trial judges to decide if one, or a compilation of several, risk factors is sufficient to overcome the presumption. This individualized approach begets litigation and leaves uncertain any particular outcome.

Recommendation 4: Preclude smoking, as it is a significant risk factor for both hypertension and heart disease. Other risk factors are too loosely tied to the conditions of hypertension and heart disease so the same recommendation should not be applied to them. Case in point: one can have one of all of the risk factors and never develop disease. Conversely, one can be free of all risk factors and develop disease.

Supported by Task Force Members: Michael Clelland, Gamy Mitchell, Peter O'Bryan, Jim Tolley


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2. Legal Issues Which Present Challenges to the Defense of Presumption Claims & Proposed Statutory Changes (Prepared by task force member Attorney Alan Kalinoski, who represents governmental entities).

[a) Minimum Time of Emvlovment -- Establishment of a minimum period of time an individual must be employed with the current employer to be eligible for a disability presumption.

Recommendation 5: An individual must be employed with the current employer for at least 10 years to be eligible for a disability presumption.


[b) Maximum Ape -- Establishment of a maximum age for an individual to be eligible for benefits under the disability presumption laws.

Recommendation 6: An individual must be under 37 years old to be eligible for a disability presumption.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Alan Kalinoski, , Timothy McCausland, Tommy Wright

Physical Examination -- Establishment of a uniform requirement that all covered employees successfully pass a physical examination with the employer against whom the di~abilitybresurn~tion is being sought to be eligible for a disability presumption.

Recommendation 7: Under 8 112.18(l)(a), F.S., a firefighter, law enforcement officer, correctional officer or correctional probation officer must have successfully passed a physical examination upon entering into service with the employer as a firefighter, law enforcement officer, correctional officer or correctional probation officer, which examination failed to reveal any evidence of any condition or impairment under the disability presumption. (8175.231, F.S., for firefighters and 8185.34, F.S., for municipal police should be amended to conform.)

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Alan Kalinoski, Timothy McCausland, Gany Mitchell

(d) Anv Evidence -- Determination as to what constitutes "any evidence" of hypertension, heart disease or tuberculosis on the physical examination performed upon the employee entering into service with the employer against whom the disability presumption is being sought.

Recommendation 8: Any evidence of elevated blood pressure (defined as systolic pressure of 130 or higher or diastolic pressure of 80 or higher), as well as any EKG or other cardiac, coronary artery or heart abnormality, or positive tuberculosis test identified on the physical examination performed upon


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the employee entering into service with the employer against whom the disability presumption is being sought shall be considered evidence of hypertension, heart disease and/or tuberculosis as a basis for denying application of a disability presumption.


_(e) Definition of Heart Disease -- Clarification as to what medical conditions fall within the definition of "heart disease" and the type(s) of hypertension which should be covered by $1 12.18, F.S.

Recommendation 9: Disability presumptions for heart disease and hypertension shall be limited to coronary artery disease and arterial or cardiovascular hypertension resulting in both disability and permanent impairment.


(0 M i u m disabilitv veriod - Establishment of a minimum amount of time a person would be required to be incapacitated from performing their work as a result of treatment for a covered condition to meet the "disability" requirement to be eligible for a disability presumption.

Recommendation 10: To be eligible to receive benefits for any disability presumption, a person would be required to be incapacitated from performing their work for a minimum of 14 contiguous days as a result of treatment for a covered condition.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Alan Kalimoski, Timothy McCausland, Gany Mitchell

@) Medical evidence necessary to rebut vresumvtion - Specificity as to what medical evidence can be considered to rebut application of a disability presumption.

Recommendation 11: Risk factors and epidemiological data relating to non-work-related conditions unique to an individual, such as blood cholesterol, body mass index, history of alcohol use, family history of hypertension andlor heart disease, diabetes, and other medical conditions or behaviors that are associated with the disease or condition subject to a disability presumption shall be considered as a basis for the denial or rebuttal of the application of a disability presumption.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Alan Kalimoski, Timothy McCausland, Tommy Wright

(h) Tobacco use as risk factor: Establishment of a forfeiture provision of a disability presumption due to tobacco use.

Final Report January 1.2012

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Recommendation 12: An individual shall forfeit a disability presumption if the individual has been or is a user of tobacco products.

Supported by Task Force Members: Peter O'Bryan, RJ. Castellanos, Alan Kalinoski, Timothy McCausland, Gany Mitchell

(i) Clear burden of vroof needed to rebut - Clarification as to the burden of proof that would be required to rebut application of a disability presumption.

Recommendation 13: A disability presumption shall be overcome by a preponderance of the evidence.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Alan Kalmoski, Timothy McCausland, Tommy Wright

W Coverage uniformity - Establishment of uniformity as to the provisions of 112.18(1) (b), Florida Statutes, as to all covered employees.

Recommendation 14: The provisions of section 1 12.1 8(l)(b), Florida Statutes, relating to a workers' compensation claim and departure from a prescribed course of treatment shall apply to firefighters (these provisions are already applicable to a law enforcement officer, correctional officer, or correctional probation officer).

Supported by Task Force Members: Peter @Bryan, R.J. Castellanos, Alan Kalmoski , Timothy McCausland, Tommy Wright

(k) Clear impairment guidelines: Establishment of appropriate guidelines as to permanent impairment for disability presumption claims brought pursuant to 1 12.18, Florida Statutes.

Recommendation 15: The Florida Uniform Permanent Impairment Rating Schedule shall not apply to any disability presumption claim. Permanent impairment for any disability presumption claim shall be determined pursuant to specific impairment guidelines established to be solely applicable to disability presumption claims.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Alan Kalimoski, Timothy McCausland

(1) Se~arate dates of accident - Case law applicable to claims for disability presumptions currently creates a forum for serial filings of separate dates of accident for any and every date that a covered individual may incur disability for the same covered condition. This leads to confusion and promotes litigation between employers, carriers and reinsurers, often involving the same covered condition. Establishment of a single date of accident for any covered condition will reduce disputes and litigation between employees, employers, carriers, and reinsurers involving disability presumption claims.


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Task Force on Public Employee Disability Presumptions a Recommendation 16: The date of accident for an individual bringing any claim for any disability presumption shall be limited to the date that the employee first incurs disability as a result of treatment for a covered condition. Any subsequent period(s) of disability would not result in a new date of accident, but would be referred to the original date of accident.


B. General Application of Presumption Laws and Mitigation of Claim Costs (Not involving Evidentiary Standards or Burden of Proof Issues).

1. Firefighter Oualification for Emvlowhent

Risk factors including tobacco use directly impact fitness for duty and should be considered as criteria for employment (Attachment 9).

Recommendation 17: To amend §633.34(5), F.S., any person applying for employment as a firefighter must:

(5) Be in good physical condition as determined by a medical examination given by a physician, surgeon, or physician assistant licensed to practice in the state pursuant to Chapter 458; an osteopathic physician, surgeon, or physician assistant licensed to practice in the state pursuant to Chapter 459; or an advanced registered nurse practitioner licensed to practice in the state pursuant to Chapter 464. Such examination may include, but not be limited to histom and vrofile review and analysis of risk factors and evidemiological data related to non-work related conditions such as tobacco vroducts use. body mass index. high cholesterol. alcohol use, familv histom of heart disease or hvoertension, and provisions of the National Fire Protection Association Standard 1582. A medical examination evidencing good physical condition shall be submitted to the division, on a form as provided by rule, before an individual is eligible for admission into a firefighter training program as defined in 5 633.35.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Alan Kalinoski , Timothy McCausland, Garry Mitchell

Recommendation 18: To add a new provision as §633.34(7), F.S., any person applying for employment as a firefighter must:

m For individuals hired after July 1.2012. those emvlovees must continue to be a non-user of tobacco products with the emuloving entitv during their emvlovment as a firefighter.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Alan Kalinoski , Timothy McCausland, Gany Mitchell, James Tolley


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2. Emvlovment Psychological Evaluations and Counseling Services


Hiring selection modules should be addressed to incorporate the psychological requirements of the job along with the physical requirements of the job. Once employees are selected and hired, on-going mental health issues relating to the job should be addressed. Agencies should promote and make mental health services to all disability presumption eligible employees who want and need these services.

Recommendation 19: A psychological test should be used as a pre-employment tool to assess fitness for duty. Psychological evaluation tools already exist; however, a psychologist is required to administer such a test and interpret the results. Criteria should be developed to determine agency actions based upon test results.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos , Timothy McCausland, Gamy Mitchell

Recommendation 20: Professional mental health counseling services should be available to employees after a traumatic event, and as needed as a preventive measure. Counseling services would be contingent on budgetary considerations and should apply as an on-going resource to employees covered under the presumption law to reduce risk for hypertension and heart disease problems resulting from negative impacts io mental health.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos , Timothy McCausland, Gamy Mitchell

3. Emplovment Fitness and Follow-Uv

Recommendation 21: Minimum fitness standards as to body mass ratio, lifting strength, cardio vascular endurance, alcohol consumption, and tobacco product use should be required to be established by all governmental employers for all employees benefitting fiom the disability presumption. Fitness for duty should be determined before an employee is selected and hied, and should be incorporated as a routine part of continuing employment (Attachment 9).

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Timothy McCausland, Gamy Mitchell, Tommy Wright

Recommendation 22: Minimum hiring standards for fitness should be developed and provided to the physicians assisting with the pre-employment evaluation.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos , Timothy McCausiand, Gamy Mitchell; Tommy Wright

Recommendations 23: I f an employee requires clearance because of information reported on a pre- employment form, agencies should obtain detailed physician follow-up evaluations and recommendations and these should be maintained in the employment records. Storage and access to the employment records should be uniform throughout the agencies.


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Supported by Task Force Members; Peter O'Bryan, R.J. Castellanos, Gany Mitchell, Tommy Wright

Recommendations 24: After initial employment, employees' fitness should continue to be monitored so that issues can be identified and requirements for ongoing employment can be developed. Failure to maintain baseline fitness levels (blood sugar, body fat index, cholesterol count, etc) will void the presumption. Fla. Statutes 112.18(l)(b)l.a should apply to firefighters.

The workday should include time for stress-reducing or health-related activities.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Gany Mitchell

4. Health and Wellness Website and/or Newsletter

Recommendation 25: Health and wellness promotion should be incorporated by design into agency operations and health and wellness information should be available and accessible to employees at work and away from work. Most governmental employers are self insured for health care as well as workers compensation. They must pay for medical care either directly, or through premiums, and so the "cost" of presumption claims may be more limited than what has been shown.

Institute Wellness Programs which have resulted in reductions in the number, and cost, of presumption (and other) claims. Orange County Fire Deparhnent's IAFFIIAFC Wellness Initiative is a model case study (Attachment 10). There, costs were reduced by two-thirds. The benefit of that approach was that the presumption remained fully intact, and there were healthier off~cers. Conversely, no matter how much or how little the presumption is changed, without some sort of wellness initiative, a fraction of the workforce will remain unhealthy. If the employer is paying for medical care, whether under workers comp or through group health, the medical treatment for disease is more expensive than reducing risk factors through a wellness initiative. The elimination of risk factors like obesity, smoking, sedentary lifestyle, etc. can impact the development of heart disease.


Recommendation 26: A website and/or newsletter should be developed or co-opted to disseminate health information to employees on a regular basis. Maintaining such a website is a cost-effective way to generate information on wellness and safety.


a) A help board or bulletin board should be prominently displayed and regularly updated with information and hotline telephone numbers to make employees aware those additional wellness resources are available to them within their community.


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b) The newsletter or website should highlight those employees who have not only returned to work after treatment for a presumption-related illness, but have also adopted a healthy lifestyle.

c) Individuals who are out due to illness should be provided positive feedback, such as a get-well card, to demonstrate that they and their work are valued.

5. Mentoring Program

Recommendation 27: Personal contact and interactive support systems among colleagues should be developed to provide employees a vehicle to address traumatic events and release anxiety and frustration, and to receive guidance and insight in a mutually supportive environment (Attachment 9).

Supported by Task Force Members: Peter O'Bryan, RJ. Castellanos, Michael Clelland , Timothy McCausland, Garry Mitchell, Jim Tolley

If not already in place, a mentoring program should be established to pair together employees for the purpose of providing peer support.

a) The program should be made available for current employees as well as new hires.

b) Mentoring should be encouraged to take place outside of the workplace in the event that it is not practical or possible to build the time for this activity into the workday.

c) Departments should, where possible, train employees on peer-support skills (particularly veteran employees, who will have the most valuable experience to offer in a mentoring situation).

6. Actuarial Review of the In Line of Dutv Claims Costs

Currently, limited information exists as to the true costs of "in line of duty" disability claims for state and local governments involving the application of disability presumptions. A review of current and projected costs for these claims by an actuary will help state and local governments obtain better information as to the impact of these claims.

Recommendation 28: That the Legislature provide funding for an actuarial special study to determine the funding costs of presumption claims for in-line-of-duty disability presumptions.

Supported by Task Force Members: Peter O'Bryan, R.J. Castellanos, Timothy McCausland, G q Mitchell, Tommy Wright

Recommendation 29: The presumption should not be available as a worker's compensation provision if an employee is covered by an employer-sponsored health insurance program.

Supported by Task Force Members: Alan Kalinoski, Timothy McCausland, Tommy Wright

Final Report Page 27 January 1.2012


The undersigned are the duly appointed members of the Task Force on Public Employee Disability Presumptions, as authorized by Chapter 2011-216, Laws of Florida. The Task Force members hereby respectfully submit this report for consideration by the Legislature, Governor and Chief Financial Officer of the State of Florida.

Michael Clelland, Esq. Date

Honorable Peter O'Bryan 17

Date

131 3 0 / 1 / W e s Tolley Date

Alan Kalinoski, Esq. Date

Gamy Mitchell Date .& I

TO&^ Wright, E S ~ . ~ ate'

/ t / 2 9 / / , ~3. Castellanos Date


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The undersigned are the duly appointed members of the Task Force on Public Employee Disabilitv ~resumptio~s, as authorizedb; chapter 201 1-216, Laws of Florida. The Task ~ o i c e members hereby res~ecthllv submit this report for consideration by the Legislature, Governor and Chief Financial 0fiicer of ihe State of Florida.

James Tolley /7 Date

Date /

3 ' L I Date

Tommy Wright, Esq. Date

Date

Timothy J. McCausland Date


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Attachments

Attachment 1 :

Attachment 2:

Attachment 3:

Attachment 4:

Attachment 5:

Attachment 6:

Attachment 7:

Attachment 8:

Attachment 9:

Chapter 201 1-216, Laws of Florida

Task Force Meeting Agendas

State of Florida Data Tables

Florida League of Cities Data Tables

Florida Sheriffs' Association Data Tables

National Council on Compensation Insurance State Comparison

Section 112.18, F.S., Presumption Law

Recent legislation amending presumption- Chapter 2010 -275, Laws of Florida.

Interagency Advisory Council Report on Presumption Claims

Attachment 10: Orange County Fire Department Wellness Program Data

Attachment 1 1 : Florida Mortality Report


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