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Relationship Between Stressfulness of Claiming for Injury Compensation and Long-Term Recovery A Prospective Cohort Study


Publication Date: 
February 12, 2014
Journal Article
Bibliography: Genevieve Grant, Meaghan O'Donnell, Matthew Spittal, Mark Creamer and David M. Studdert, Relationship Between Stressfulness of Claiming for Injury Compensation and Long-Term Recovery A Prospective Cohort Study, JAMA Psychiatry, February 12, 2014.



Importance  Each year, millions of persons worldwide seek compensation for transport accident and workplace injuries. Previous research suggests that these claimants have worse long-term health outcomes than persons whose injuries fall outside compensation schemes. However, existing studies have substantial methodological weaknesses and have not identified which aspects of the claiming experience may drive these effects.

Objective  To determine aspects of claims processes that claimants to transport accident and workers’ compensation schemes find stressful and whether such stressful experiences are associated with poorer long-term recovery.

Design, Setting, and Participants  Prospective cohort study of a random sample of 1010 patients hospitalized in 3 Australian states for injuries from 2004 through 2006. At 6-year follow-up, we interviewed 332 participants who had claimed compensation from transport accident and workers’ compensation schemes (“claimants”) to determine which aspects of the claiming experience they found stressful. We used multivariable regression analysis to test for associations between compensation-related stress and health status at 6 years, adjusting for baseline determinants of long-term health status and predisposition to stressful experiences (via propensity scores).

Main Outcomes and Measures  Disability, quality of life, anxiety, and depression.

Results  Among claimants, 33.9% reported high levels of stress associated with understanding what they needed to do for their claim; 30.4%, with claim delays; 26.9%, with the number of medical assessments; and 26.1%, with the amount of compensation they received. Six years after their injury, claimants who reported high levels of stress had significantly higher levels of disability (+6.94 points, World Health Organization Disability Assessment Schedule sum score), anxiety and depression (+1.89 points and +2.61 points, respectively, Hospital Anxiety and Depression Scale), and lower quality of life (−0.73 points, World Health Organization Quality of Life instrument, overall item), compared with other claimants. Adjusting for claimants’ vulnerability to stress attenuated the strength of these associations, but most remained strong and statistically significant.

Conclusions and Relevance  Many claimants experience high levels of stress from engaging with injury compensation schemes, and this experience is positively correlated with poor long-term recovery. Intervening early to boost resilience among those at risk of stressful claims experiences and redesigning compensation processes to reduce their stressfulness may improve recovery and save money.

Injury is an important contributor to the burden of disease, accounting for 10% of deaths and 11% of disability-adjusted life years globally in 2010. A substantial proportion of nonfatal injuries occur on the road or in the workplace. In developed and middle-income countries, persons who sustain injuries in these settings are often eligible to claim monetary benefits from injury compensation schemes. Although a central goal of such schemes is to help return injured persons to work and health, there are growing concerns that they may have the opposite effect.

By comparing the postinjury health status of patients who claim compensation with that of patients who do not claim, more than 100 studies have concluded that recovery trajectories are worse among claimants. Other studies have linked receipt of certain benefits from compensation schemes to slower recoveries. Commentators have posited a causal relationship between “exposure” to compensation systems and ill health. One explanation for this effect focuses on claimants’ choices and behaviors. Another points to stressful aspects of the claims process itself, including adversarialism and clinical scrutiny, as independent determinants of poor health outcomes.

The nature, extent, and cause of compensation-related health effects remain unclear, largely as a result of fundamental limitations in the extant research. This study was designed to avoid these limitations. We observed a cohort of injured patients for 6 years and then interviewed those who had pursued claims in transport accident and workers’ compensation schemes about their experience. Our analysis investigated compensation-related health effects within this sample of claimants. The study aims were to determine which aspects of the process claimants found stressful and whether stressful experiences were associated with poorer long-term recovery.